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A  CLINICAL  TEXT-BOOK 


Surgical  Diagnosis  and  Treatment 


PRACTITIONERS  AND   STUDENTS   OF 
SURGERY  AND.  MEDICINE. 


BY 

J.  W.  MACDONALD,  M.D., 

Graduate  in  Medicine  of  the  Univeksity  of  Edinburgh;    Licentiate  of  the   Royal 

College  of  Surgeons,  Edinburgh  ;    Professor  of  the  Practice  of  Surgery  and 

OF  Clinical  Surgery  in  Hamline  University  ,  Minneapolis,  etc. 


WITH  328  ILLUSTRATIONS. 


PHILADELPHIA  : 

W.    B.    SAUNDERS, 

925    Walnut    Street. 
1898. 


Copyright,  1897, 
By    \fV.     B.    SAUNDERS, 


ELECTROTYPED  BY  PRFcq  nv 

WESTCOTT  4  THOMSON,  PHILADA.  W.  B.  SAUNDERS    PHILADA. 


TO 

JOSEPH    BELL,  Esq.,  F.R.C.S., 

FROM  WHOSE  LIPS   I   RECEIVED   MY   FIRST   LESSONS  IN  SURGERY, 
THIS   WORK    IS    GRATEFULLY    DEDICATED    BY 

THE    AUTHOR. 


PREFACE. 


The  rapid  advances  made  in  the  art  of  surgery  have  caused  the 
literature  of  the  science  to  grow  apace.  Systems  of  surgery  in  many 
volumes,  and  text-books  of  large  dimensions,  are  now  deemed  neces- 
sary to  cover  the  field.  The  practical  part  of  the  surgeon's  work  is, 
however,  almost  limited  to  two  questions  which  he  must  answer  every 
time  his  professional  advice  or  help  is  sought.  The  first  question  is, 
"What  is  the  disease  or  injury?"  The  second  question  is,  "What  is 
the  proper  treatment  ?  " 

While  I  would  not  for  a  moment  underestimate  the  importance  of  a 
profound  study  of  the  principles  of  surgery,  of  surgical  pathology,  or 
of  bacteriology,  the  present  work  will  be  confined  to  a  solution  of  the 
two  questions  just  mentioned  with  the  view  of  putting  into  the  hands 
of  students  and  practitioners  a  single  volume  containing  the  most 
practical  part  of  practical  surgery. 

The  young  practitioner  is  often  embarrassed  by  not  knowing  how 
to  make  a  systematic  examination  in  a  case  of  injury,  and  he  may  be 
placed  at  a  disadvantage  by  the  criticism  of  excited  bystanders.  The 
man  who  goes  about  the  examination  of  his  patient  in  a  systematic 
manner,  leaving  nothing  undone  and  guarding  against  all  contingencies, 
will  not  only  command  the  approval  of  the  patient  and  his  friends,  but 
will  protect  himself  against  dangerous  errors.  In  the  following  pages 
care  is  taken  to  make  the  examination  of  each  disease  or  injury  sys- 
tematic and  comprehensive,  and,  when  possible,  directions  are  laid  down 
as  to  the  methods  of  examination. 

The  surgery  of  the  eye,  the  ear,  and  the  skin  is  now  so  generally  left 
to  the  care  of  specialists  in  these  respective  fields  that  I  have  thought 
it  best  to  refer  the  reader  to  works  exclusively  devoted  to  these  studies. 

While  the  field  of  medical  diagnosis  has  been  well  covered  by  such 
excellent  works  as  those  of  DaCosta,  Musser,  Vierordt,  and  others, 
surgical  diagnosis  up  to  the  present  time  is  not  dealt  with  in  any  work 
that  claims  to  represent  the  most  recent  surgical  knowledge ;  at  the 
same  time  the  profession  may  almost  be  said  to  have  stampeded  to 
surgery.  This  very  popularity  of  surgery,  especially  among  young 
practitioners,  is  not    free  from  a   serious   danger — viz.   that    in   being 


8  PREFACE. 

absorbed  with  the  thouf^ht  of  the  operation  that  may  be  required  the 
mind  of  the  surt:^eon  dwells  too  lightly  upon  the  diai^nosis  of  the  dis- 
ease. I  send  this  work  upon  its  mission  with  the  hope  that  the  reader 
ma}'  be  led  into  the  habit  of  making  every  examination  systematic  and 
exhausti\e,  that  he  may  find  help  in  the  diagnosis  of  difficult  cases, 
and  that  his  labors  may  be  thereby  lessened  and  his  responsibilities 
lightened. 

I  take  this  opportunity  of  expressing  my  deep  obligations  to  Drs. 
Hoegh,  Bartlett,  Hall,  Ferro,  and  others  for  valuable  suggestions ;  to 
Dr.  Florence  M.  Baier,  Dr.  Findley,  Dr.  Mowat,  and  Dr.  C.  B.  Roberts 
for  long-continued  and  patient  labor  in  collecting  and  arranging  mate- 
rials ;  and  to  the  many  friends  who  have  contributed  illustrations. 

J.  W.  MACDONALD. 
Minneapolis,  November,  1S97. 


CONTENTS. 


CHAPTER    I. 

PAGE 

General   Examination  of  Patients 17 

Introduction,  17. — Information  obtained  from  the  Patient  or  his  Friends,  i8. — 
Influence  of  Age,  Sex,  Heredity,  Habits,  etc.,  18. — History  of  Present  Disease  or 
Injury,  19. — General  Examination  of  the  Patient,  19. — General  Appearance,  Posi- 
tion, Surface  Markings  and  Changes  of  Contour,  Condition  of  the  Sicin,  etc.,  20. — 
Temperature,  Local  and  General,  21. 

CHAPTER   II. 

Examination  of  the  Vascular  System 22 

I.  The  Heart  and  Pericardium,  22. — Overdistention  of  the  Ventricles,  22. — 
Effusion  into  the  Pericardium,  23. — Injuries  of  the  Heart,  24. — Wounds  of  the 
Heart,  24. 

II.  Examination  of  the  Veins,  24. — Wounds  of  Veins,  24. — Thrombosis, 
25. — Varix,  25. — Nevus,   27. 

III.  Examination  of  the  Arteries,  27. — Wounds,  27. — Rupture,  28. — Acute 
Arteritis,  29. — Chronic  Arteritis,  29. 

IV.  Aneurysm,  32. — Symptoms  Common  to  Aneurysm  in  General,  32. — Treat- 
ment of  Aneurysm,  34. 

V.  Special  Aneurysms,  35. — Aneurysm  of  the  Arch  of  the  Aorta,  35. — Aneu- 
rysm of  the  Ascending  Portion  of  the  Arch,  36. — Aneurysm  of  the  Transverse  Por- 
tion of  the  Arch,  37. — Aneurysm  of  the  Descending  Portion  of  the  Arch,  38. — 
Innominate  Aneurysm,  39. — Treatment  of  Aortic  Aneurysm,  39. — Aneurysm  of  the 
Carotid,  41. — Vertebral  Aneurysm,  41. — Orbital  or  Ophthalmic  Aneurysm,  4I. — 
Subclavian  Aneurysm,  42. — Axillary  Aneurysm,  42. — Aneurysm  of  the  Abdominal 
Aorta,  43. — Aneurysm  of  the  Branches  of  the  Abdominal  Aorta,  44. — Iliac  Aneu- 
rysm, 44. — Femoral  Aneurysm,  46. — Popliteal  Aneurysm,  46. — Traumatic  Aneu- 
rysm, 47. — Varicose  Aneurysm,  48. 

CHAPTER   III. 
Injuries  and  Diseases  of  the  Osseous   System 49 

I.  Fractures,  49. — How  to  Deal  with  Accidents  and  Emergencies,  49. — Class- 
ification of  Fractures,  50. — Diagnosis  of  Fractures  in  General,  52. — Complications 
of  Fracture,  55. — Diagnosis  and  Treatment  of  Special  Fractures,  58. — The  Nasal 
Bones,  58. — The  Malar  Bone,  59. — The  Upper  Jaw,  59. — The  Lower  Jaw,  60. — 
The  Clavicle,  60. — The  Hyoid  Bone,  62. — The  Sternum.  63. — The  Ribs,  63. — 
The  Scapula,  64. — The  Humerus,  65. — The  I'lna,  71. — Fracture  of  the  Radius 
and  Ulna  together,  72. — Fracture  of  the  Radius  alone,  73. — The  Metacarpal  Bones, 
75. — The  Phalanges,  75. —The  Pelvis,  75.— The  Femur,  77. — The  Patella,  82. — 
The  Tibia,  84. — The  Fibula,  86. — The  External  Malleolus,  87. — The  Astragalus, 
87. — Compound  Fractures,  88. — Amputation  after  Injury,  88. 

II.  Diseases  of  Bone,  89. — Inflammation,  89. — Osteoperiostitis,  90. — Osteo- 
myelitis, 91. — Sejitic  Inflammation  of  Bone,  91. — Necrosis,  92. — Chronic  Inflam- 
mation of  Bone,  93. — Tubercular  Ostitis,  94. — Syphilitic  Diseases  of  Bone,  95. — 
Fragilitas  Ossium,  96. — Rachitis,  96. — Osteomalacia,  97. — Actinomycosis,  97. — 
Tumors  of  Bone,  98. — Malignant  Tumors  of  Bone,  loi. — Acromegaly,  105. 


lO  CONTENTS. 

CHAPTER   IV. 

PAGB 

Injuries  and  Diseases  of  Muscles,  Tendons,  and  Burs^  ....  105 

Strain,  105. —  Rupture,  105. — Wounds,  106. — Myaljjia,  106. — Myositis,  106. — 
Tenosynovitis,  107. — Ganglion,  109. — Diipuytren's  Contraction,  109. — Diseases  of 
Bursa',  no. — Bursitis,  no. 

CHAPTER   V. 
Injuries  and  Diseases  of  Joints m 

I.  Injuries  of  Joints,  in. — Contusions,  ni. — Sprains,  in. — Wounds  of  Joints, 
113. — Dislocations,  I14. — Diagnosis  of  Special  Dislocations,  118. — The  Lower  Jaw, 
118. — Injuries  about  the  Clavicle  and  Shoulder,   1 19. — The  Clavicle,   120. — The 

Sternum,  122. — The  Shoulder,  123. — The  Elbow,   127. — The  Wrist -joint,  130. 

The  Ilip-joint,  131. — The  Knee-joint,  139. — The  Patella,  140. — The  Fibula,  140. 
— The  Ankle.  140. — Subastragaloid  Dislocations,  142. — Dislocation  of  the  Astrag- 
alus, 142. — Loose  Bodies  in  Joints,  142. — Displacement  of  a  Semilunar  Cartilage, 
144. 

n.  Diseases  of  Joints,  144. — Examination  of  Joints  for  Disease,  145. — Sim- 
ple Acute  Synovitis,  145.-  Dry  Synovitis,  I47. — Chronic  Synovitis,  147. — Arth- 
ritis, 148. — Acute  Arthritis  w-nh  Suppuration,  150. — Pyemic  Arthritis,  150. — Tuber- 
cular Arthritis,  152. — Tuberculosis  of  Special  Joints,  153. — The  Hip-joint,  153. — 
The  Sacro-iliac  Joint,  158. — The  Knee-joint,  161. — The  Ankle-joint,  162.— The 
Shoulder-joint,  163. — The  Elbow-joint,  163. — The  Wrist-joint,  164.— The  Phalan- 
geal Joints,  164.  —  Rheumatic  Arthritis,  164. — Gonorrheal  Arthritis,  1 64. — Neuro- 
pathic Arthritis,  or  Charcot's  Disease,   165. — Gouty  Arthritis,  165. 

CHAPTER   VI. 
Injuries  and  Diseases  of  the  Digestive  System 166 

I.  The  Lips,  Palate,  Jaws  and  Gums,  Tonsils,  Pharynx,  and  Esoph- 
agus, 166. — The  Lips,  166. — Hare-lip,  166. —  Macrostoma  and  Microstoma,  170. 
— Nevi,  171. — Other  Tumors  of  the  Lips,  171. — Furuncle  and  Carbuncle,  172. — 
Hypertrophy  of  the  Lips,  172. — Wounds,  172. — Inflammation,  172. — Epithelioma, 
173. — The  Palate,  174. — Cleft-Palate,  174. — Tumors  of  the  Palate,  179. — Syph- 
ilis of  the  Palate,  179. — The  Mouth,  179. — Salivary  Calculus,  179. — Ranula, 
180. — The  Tongue,  180. — Malformations,  180. — Injuries,  181. — Diseases  of  the 
Tongue,  181. — Tumors  of  the  Tongue,  185. — The  Jaws  and  Gums,  186. — 
Deformities,  186. — Chronic  Affections  of  the  Jaw,  186. — Diseases  of  the  Temporo- 
maxillary  Articulation,  192. — The  Tonsils,  193. — Tonsillitis,  193. — Hypertrophy 
of  the  Tonsils,  194. — Calcareous  and  Cheesy  Concretions,  194. — Sarcoma  and  Car- 
cinoma, 195. — The  Pharynx,  195. — Retropharyngeal  Abscess,  195. — Tumors, 
196. — The  Esophagus,  196. — Malformations,  196. — Pouches  or  Diverticula,  196. 
— Stricture,  196. 

n.  Diseases  and  Injuries  of  the  Abdomen,  201. — Examination  of  the 
Abdomen,  201. — Abdominal  Topography,  201. — Objective  Symptoms,  203. — 
Inspection,  203. — Palpation,  204. — Percussion,  205. — Auscultation,  205. — Explor- 
atory Puncture  and  Incision,  206. — Injuries  of  the  Abdomen,  207. — Contusions, 
207. — Wounds  of  the  Abdomen,   208. 

HI.  Examination  of  the  Stomach,  215. — Inspection,  Palpation,  Percussion, 
215. — Injuries  and  Diseases  of  the  Stomach,  216. — Rupture,  217. — Foreign  Bodies, 
217. — Mechanical  Fixation  of  the  Stomach,  218. — Ulcer,  218. — Gastric  Fistula, 
219. — Cancer,  220. — Stricture  of  the  Cardiac  Orifice,  229. — Dilatation  of  the  Stom- 
ach, 231. 

IV.  Diseases  and  Injuries  of  the  Intestines,  233. — Examination  of  the 
Intestines,  233. — Carcinoma,  234. — Acute  Intestinal  Obstruction,  237. — Intussus- 
ception, 246. — Volvulus,  253. — Strangulation  by  Bands,  253. — Chronic  Intestinal 
Obstruction,  253. 

V.  Hernia,  255. — Irreducible  Hernia,  259. — Incarcerated  Hernia,  260. — Strang- 
ulated Hernia,  260. — The  Radical  Cure  of  Hernia,  263. — Championniere's  Ope- 
ration, 265. — Macewen's  Operation,  267. — Bassini's  Operation,  268. — Halsted's 
Operation,  268. — The  Radical  Cure  of  Femoral  Hernia,  270. — Palliative  Treat- 
ment of  Hernia,  270. — Umbilical  Hernia,  271. — Ventral  Hernia,  272. — Lumbar 
Hernia,  273. — Obturator,  Perineal,   and  Diaphragmatic   Hernias,  273. 


CONTENTS.  1 1 

PAGE 

VI.  Appendicitis,  273. — Causes,  274. — Symptoms,  275. — Diagnosis,  276. — 
Classification,  277. — Prognosis,  279. — Treatment,  279. 

VII.  Diseases  and  Injuries  of  the  Peritoneum,  281. — Functions  of  the 
Peritoneum,  2S1. — Plastic  Peritonitis,  282. — Septic  Peritonitis,  283. — Suppurative 
Peritonitis,  285. — Tubercular  Peritonitis,  286.— Carcinoma  of  the  Peritoneum,  288. 
— Sarcoma  of  the  Omentum,  289. — Benign  Tumors  of  the  Peritoneum,  289. — Rup- 
ture of  the  Peritoneum,  289. — Wounds  of  the  Peritoneum,  289. 

VIII.  Injuries  and  Diseases  of  the  Liver,  290. — E.xamination  of  the  Liver, 
291. — Rupture  of  the  Liver,  291. — Wounds  of  the  Liver,  291.— Abscess  of  the 
Liver,  292. — Hydatids  of  the   Liver,  296. — Floating  Liver,  298. 

IX.  Injuries  and  Diseases  of  the  Gall-bladder,  298. — Gall-stones,  299. — 
Pathological  Changes  produced  by  Gall-stones,  304. — Operations,  308-313. — 
W^ounds  of  the  Gall-bladder.   313. — Empyema  of  the  Gall-bladder,  314. 

X.  Diseases  and  Injuries  of  the  Pancreas,  314. — Functions  of  the  Pan- 
creas, 314. — Pancreatic  Hemorrhage,  315. — Suppuration  and  Abscess  of  the  Pan- 
creas, 315. — Cysts  of  the  Pancreas,    315. — Cancer  of  the  Pancreas,  316. 

XI.  Injuries  and  Diseases  of  the  Spleen,  31 7. ^Examination,  317. — 
Wounds  of  the  Spleen,  317. — Abscess,  319. — Rupture,  320. — Cysts,  320. — Carci- 
noma and  Sarcoma,  320. 

XII.  Diseases  and  Injuries  of  the  Rectum  and  Anus,  320. — Examination, 
320. — Inspection,  320. — Digital  Examination,  320. — Examination  with  the  Spec- 
ulum, 321. — Manual  Examination,  321. — Wounds  and  Other  Injuries  of  the  Rec- 
tum, 322. — Foieign  Bodies  in  the  Rectum,  322. — Hemorrhoids,  323. — Prolapsus 
Ani,  327. — Prolapsus  Recti,  328. — Pruritus  Ani,  329. — Inflammatory  Diseases  of 
the  Rectum,  330. — Proctitis,  330. — Ulceration,  330. — Periproctitis,  332. — Ischio- 
rectal Abscess,  332. — Abscess  above  Levator  Ani  Muscle,  TyT,T). — Fistula  in  ano, 
333. — Fissure  of  the  Anus,  337. — Spasm  of  the  Sphincter,  339. — Tumors  of  the 
Rectum,  339. — Papillomata,  340. — Condylomata,  341. — Fibromata,  etc.,  341. — 
Stricture  of  the  Rectum,  341. — Congenital  Malformations  of  the  Rectum  and 
Anus,  345. 


CHAPTER  VII. 
The  Genito-urinary  System 


347 


I.  Injuries  and  Diseases  of  the  Kidneys,  347. — Surgical  Anatomy,  347. — 
Injuries  of  the  Kidney,  349. — Contusion  without  Laceration  of  the  External  Tis- 
sues, 349. — Wounds  of  the  Kidney,  350. — Diseases  of  the  Kidney,  351.— Exam- 
ination, 351. — Movable  Kidney,  352. — Renal  Calculus,  354. — Nephro-lithotomy, 
357. — Nephrectomy,  357. — Perinephritic  and  Nephritic  Abscess,  360. — Surgical 
Kidney,  361. — Hydronephrosis,  363. — Pyonephrosis,  364. — Tuberculosis  of  the 
Kidney,  365. — Hydatid  Cysts,  365. — Simple  Cysts,  366. — Solid  Tumors,  366. 

II.  Injuries  and  Diseases  of  the  Ureter,  368. — Surgical  Anatomy,  368. — 
Palpating  the  Ureter,  369. — Rupture  of  the  Ureter,  369. — Ureteral  Calculus,  373. — 
Longitudinal  Ureterotomy,  373. — Other  Operations,  373. — Ureteritis,  373. — Stric- 
ture of  the  Ureter,  374. 

HI.  Injuries  and  Diseases  of  the  Bladder,  37;. — Significance  of  Symp- 
toms, 375. — Rupture  of  the  Bladder,  378. — Retention  of  Urine,  380. — Atony  of  the 
Bladder,  381. — Sacculation  and  Pouching  of  the  Bladder,  382. — Cystitis,  383. — 
Acute  Cystitis,  383. — Chronic  Cystitis,  384. — Stone  in  the  Bladder,  386. — Symp- 
toms indicating  the  Presence  of  Stone,  387. — Sounding  the  Bladder,  38S. — The 
Cystoscope,  391. — Measuring  the  Calculus,  392. — Removal  of  Stone,  393. — Contra- 
indications, 394. — Litholapaxy,  395. — Operation,  395. — Lithotomy,  399. — Lateral, 
400. — Median,  401. — Perineal  Lithotrity,  402. — Suprapubic  Lithotomy,  403. — 
Tumors  of  the  Bladder,  404. — Deformities  of  the  Bladder,  407. — Cystocele  and 
Hernia  of  the   Bladder,  409. 

IV.  Injuries  and  Diseases  of  the  Prostate,  409. — Surgical  Anatomy,  409. — 
General  Symptoms  of  Prostatic  Disease,  410. —  Hypertrophy  of  the  Prostate,  410. — 
Operative  Procedures,  415. — Double  Castration,  415. — Prostatectomy,  415. — Inflam- 
mation of  the  Prostate,  417. — Malignant  Disease  of  the  Prostate,  419. — Calculus  of 
the  Prostate,  419. — Wounds  and  Injuries  of  the  Prostate,  420. 

V.  Injuries  and  Diseases  of  the  Male  Urethra,  420. — Surgical  Anatomy, 
420. — Rupture  of  the  Urethra,  421. — False  Passages  in  the  Urethra,  422. — Foreign 


1 2  CONTENTS. 

PAGE 

Bodies  in  the  Urethra,  423. — Urethritis,  425. — Gonorrhea,  425. — Chronic  Urethritis, 
432. — Chronic  Gunorrliua,  433. — Stricture  of  the  Urethra,  434. — Urinary  Pouches, 
442. 

VI.  Injuries  and  Diseases  of  the  Male  Generative  Organs,  443. — Dis- 
eases and  Malformations  of  the  I'enis,  443. — Hypospadias,  443. — tipispadias,  445. — 
Phimosis,  445. —  Paraphimosis,  445. — Carcinoma  of  liie  Penis,  445. — Diseases  of  the 
Scrotum,  447. — Edema  and  Inllammalion,  447. — Epithelioma,  447. — Elephantiasis, 
447. — Swellings  of  the  Scrotum,  447. —  (hxhitis,  448. — Syphilitic  Testicle,  448. — 
Tubercular  Orchitis,  449. — Gouty  Orchitis,  449. — Malignant  Disease  of  the  Tes- 
ticle, 449. — Sarcoma,  449. — Carcinoma,  450.- — IJenign  Tumors,  451. — Abnormal- 
ities of  the  Testicles,  451. — Hydrocele,  451. — Hematocele,  453. — Inflammation  of 
the  Speiniatic  Cord,  453. — Encysted  Hydrocele,  454. 

CHAPTER   VIII. 
Injuries  and  Diseases  of  the  Head 455 

I.  Cerebral  Topography,  455. — The  Sensori-motor  Area,  456. — The  Area  of 
Speech,  459. — The  Areas  of  Vision  and  Hearing,  460. — The  Area  of  Sensations 
of  Smell  and  Taste,  460. — Methods  of  Determining  the  Position  of  the  Fis- 
sures, 460. 

II.  Injuries  and  Diseases  of  the  Scalp,  462. — Contusions,  462. — Cephal- 
hematoma, 402. — Wounds,  4O2. — Tumors,  463, — Horns  and  Warts,  464. — Pneu- 
matocele, 464. 

HI.  Injuries  of  the  Skull,  464. — Contusions,  464. — Osteomyelitis,  464. — Frac- 
tures of  the  \'ault  of  the  Skull,  465. — Fractures  of  the  Base,  467. 

IV.  Injuries  of  the  Brain  and  its  Membranes,  469. — Concussion  of  the 
Brain,  469. — Compression  ot  the  Brain,  470. — Intra-cranial  Hemorrhage,  472. — 
Extra-dural  Hemorrhage,  472. — Sulxlural,  Subarachnoid,  and  Cerebral  Hemor- 
rhage, 473. — Treatment  of  Intra-cranial  Hemorrhage,  473. — The  Operation  of 
Trephining,  475. — Wounds  of  the   Brain,  478. 

V.  Injuries  of  the  Cranial  Nerves,  479. — The  Olfactory  Nerve,  479. — The 
Optic  Nerve,  480. — The  Third,  Fourth,  Pifth,  Sixth,  and  Seventh  Cranial  Nerves, 
481. — The  Eighth  and  Ninth  Cranial  Nerves,  482. 

VI.  Gunshot  Wounds  of  the  Head,  482. — Wounds  of  Entrance  and  Exit, 
482. — Finding  the  Bullet,  483. — The  Telephone  Probe,  483. — Lilienthars  Probe, 
484. 

VII.  Septic  Inflammation  within  the  Cranium,  485. — Portals  of  Entrance 
of  Septic  Germs,  4S5. — Inflammation  of  the  Brain  and  its  Membranes,  486. 

VIII.  Abscess  of  the  Brain,  487. — Causes,  487. — Symptoms,  488. — Differ- 
ential Diagnosis,  492. — Treatment,  492. — Thromi)osis  of  the  Lateral  Sinus,  496. 

IX.  Cerebral  Tumors,  496. — Varieties,  496. — Symptoms,  497. — General,  497. 
— Focal,  499. — Diagnosis,  500. — Treatment,  503. — Tumors  of  the  Cerebellum,  503. 

X.  Epilepsy,  504. 

CHAPTER   IX. 
Injuries,  Diseases,  and  Deformities  of  the  Spine 506 

Surgical  Anatomy,  506. — Examination  of  the  Spine,  507. — Injuries  of  the 
Spine,  508. — Sprains,  508. — Railway  Spine,  508. — Concussion  of  the  Spinal  Cord, 
510. — Compiression  of  the  Spinal  Cord,  510. — Wounds  of  the  Back,  51 1. — Fractures 
of  the  Spine,  512. — Gunshot  Wounds  of  the  Spine,  520. — Dislocation  of  the  Spine, 
520. — Deformities  of  the  Spine,  521. — Spina  Bifida,  521. — Sacro-coccygeal  Tumors, 
525. — Curvature  of  the  Spine,  525. — Tuberculosis  of  the  Spine  (Pott's  Disease),  530. 

CHAPTER   X. 
Diseases  and  Injuries  of  the  Nerves 543 

Neuritis,  543. — Neuralgia,  544. — Injuries  of  Nerves,  547. — Wounds  of  Nerves, 
547. — Injuries  of  Special  Nerves,  550. — Facial  Nerve,  550. — Pneumogastric,  552. — 
Posterior  Thoracic,  553. — Musculo-spiral,  Radial,  Median,  and  Ulnar  Nerves,  553. 
—Sciatic,  555. 


CONTENTS.  13 

CHAPTER   XI. 

PAGE 

Injuries  and  Diseases  of  the  Respiratory  System 556 

I.  The  Nose,  556. — External  Injuries,  556. — Elephantiasis,  556. — Rhinoscle- 
roma,  556. — External  Tumors.  556. — Internal  Injuries,  557. — Parasites,  55S. — 
Rhinoliths,  55S. — Polypi,  559. — Fibro-myomata  and  Fibromata,  561. — Papillomata, 
Adenomata,  Enchondromata,  Osseous  Growths,  Angeiomata,  563. — Sarcomata,  563. 
— Carcinomata,  564. — Epistaxis,  564. — Ulcers,  566. — Lupus,  567. — Epitheliomata, 
567. — Syphilis,  56S. — Leprous  Ulcers,  570. — Rhinitis,  570. — Atrophic  Nasal 
Catarrh,' 575. — Ozena,  576. — Diphtheritic  and  Membranous  Rhinitis,  577. — Puru- 
lent Rhinitis,  577. — Diseases  and  Injuries  of  the  Septum,  577.— Deviations, 
577. — Hematomata,  580. — Abscesses.  580. — Perforation  of  the  Septum,  580. — 
Deformities,  Congenital  Malformations,  and  Defects  of  the  Nose,  580. — 
Rhinoplasty,  5S2.— Rhinoscopy,  584.— Anterior  Rhinoscopy,  585. — Posterior 
Rhinoscopy,  585. 

II.  Diseases  and  Injuries  of  the  Accessory  Sinuses  of  the  Nose,  588. — 
The  Antrum  of  Highmore,  5S8. — The  Frontal  Sinus,  591.— The  Ethmoidal  Sinuses, 
594. — The  Sphenoidal  Sinuses,  594. 

III.  Neuroses  of  the  Nasal  Passages,  594.— Anosmia,  594. — Hyperosmia 
or  Hyperesthesia  of  the  Olfactory  Nerve,  596. — Reflex  Neuroses,  596. 

IV.  The  Larynx,  597. — Laryngoscopy,  597. — Injuries  of  the  Larynx,  600. 
— Internal  Injuries,  600. — External  Injuries,  602. — Foreign  Bodies  in  the  Air-pas- 
sages, 605. — Diseases  of  the  Larynx,  608. — Laryngitis,  Catarrhal,  608. — Acute 
Infantile  Laryngitis,  609. — Chronic  Laryngitis,  61 1. — Diphtheritic  Laryngitis,  614. 
— Edema  of  the  Larynx,  614. — Abscess  of  the  Larynx,  617. — Chondritis  and  Peri- 
chondritis, 617. — Ulcers  of  the  Larynx,  619. — Tuberculosis  of  the  Larynx,  619. — 
Syphihs  of  the  Larynx,  622. — Tumors  of  the  Larynx,  623. — Benign  Tumors,  623. — 
Malignant  Tumors,  629. — Neuroses  OF  THE  Larynx,  631.— Sensory  Neurosis, 
631. — Neuralgia,  631. — Paralysis  of  Superior  Laryngeal  Nerve,  631. — Paralysis  of 
Recurrent  Laryngeal  Nerve,  632. — Paralysis  of  the  Abductors,  633. — Paralysis  of 
the  Adductors,  634. — Paralysis  of  the  Internal  Tensors,  635. — Spasm  of  the  Glot- 
tis, 635. 

V.  Stricture  and  Stenosis  of  the  Larynx  and  Trachea,  636. — Compres- 
sion-stenosis, 637. — Occlusion-stenosis,  637. 

VI.  Malformations  of  the  Larynx  and  Trachea,  638. — Tumors  of  the 
Trachea,  639. — Tracheocele,  639. 

VII.  Bronchial  Tubes,  640. — Injuries,  640. — Tumors,  640. — Tracheotomy, 
640. — Intubation  of  the  Larynx,  642. — Laryngectomy,  644. 

VIII.  The  Chest,  645.— Wounds,  645. — Effusions  into  the  Pleural  Cavity,  645. 
— Thoracotomy,  647. — Thoracoplasty,  647. — Schede's  Operation,  647. 


CHAPTER  XII. 
The   Diagnosis  and  Treatment  of  Syphilis 648 

Modes  of  Transmission,  648.— The  Primary  Sore,  649. — Differential  Diagnosis, 
650. — Treatment  of  Chancroid,  650. — Treatment  of  Chancre,  652. — The  Secondary 
Stage,  652.— The  Tertiary  Stage,  655.— Differential  Diagnosis,  655. —  Hereditary 
Syphilis,  660. 

CHAPTER    XIII. 
The  Diagnosis  and  Treatment  of  Tumors 663 

Characteristics  of  Benign  and  Malignant  Growths,  663. — Connective-tissue 
Tumors,  663. — Lipomata.  663. — Fibromata,  664. — Chondromata,  Myxomata,  Myo- 
fibromata,  Angeiomata,  Gliomata,  Neuromata,  665. — Sarcomata,  666. — Epithelial 
Tumors,  666. — Warts,  Villous  Papillomata,  666. — Intra-cystic  Papillomata,  666. — 
Psammomata,  Epitheliomata,  667. — Adenomata,  668. 


14  COA^ViNTS. 

CHAPTER    XIV. 

PAGE 

Diseases  and  Injuries  of  the  Neck 669 

Congenital  Malformations,  669. — Branchial  Cysts,  669. — Branchial  Fistula;,  670. 
— Cellulitis  of  the  Neck,  070. — Abscesses  of  tlie  Neck,  670. — Contusions,  671. — 
Wounds,  671. —  Tumors,  671. — Sypliilitic  Enlart;ement  of  the  Glands,  671. — Tuber- 
cular Glands,  671. — Malij^nant  Lymphoma,  or  Ilodgkin's  Disease,  672. — Actino- 
mycosis, 673. — Other  Tmnors  of  the  Neck,  673. — Diseases  of  the  Parotid 
Gland,  673. — Parotiditis,  673. — Tumors  of  the  Parotid,  673. — Diseases  of  the 
Thyroid  Gland,  674. — Goiter,  or  Bronchocele,  674. 

CHAPTER   XV. 
Injuries  and  Diseases  of  the  Breast 675 

Piiysiolo^ical  Changes  in  the  Breast,  675. — Examination  of  the  Breast,  675. — 
Diseases  of  the  Mammary  Gland,  676. — Mastitis  or  Manimitis,  676. — Neurosis  of 
the  Breast,  677. — Tumors  of  the  Breast,  678. — Benign  Tumors,  678. — Malignant 
Tumors,  679. — Sarcoma,  679. — Carcinoma,  679. — Scirrhus,  6S0. — Cardinal  Symp- 
toms of  Cancer,  680. — Medullary  Cancer,  681. — Operation  for  Removal  of  the 
Breast  (Halsted's),  682. 

CHAPTER   XVI. 

Diseases  and  Injuries  of  the   Female  Generative  Organs  .    .    .  685 

I.  Methods  of  Examination,  685. — Personal  Histor)',  6S5.^Positions  for 
Examination,  686. — Vaginal  Examination,  688. — Bimanual  Examination,  689. — 
Rectal  Examination,  690. — Inspection  of  the  External  Genitalia,  691. — Artificial 
Dilatation  of  the  Uterus,  693. — Examination  of  the  Urethra  and  Bladder,  694. — 
Examination  of  the  Ureters,  694. — Method  of  Catheterizing  the  Ureters,  694. 

II.  Anomalies  of  the  Female  Genital  Organs,  695. — Hermaphrodism,  695. 
— Anomalies  of  the  External  Genital  Organs,  695. — Anomalies  of  the  Hymen,  695. 
— Hypertrophy  of  the  Clitoris,  696. — Anomalies  of  the  Internal  Genital  Organs,  696. 

III.  Traumatic  Lesions  of  the  Female  Genital  Tract,  698. — Injuries  of 
the  Vulva  and  Perineum,  698. — Injuries  of  the  Vagina,  698. — Injuries  due  to  Par- 
turition, 698. — Operations,  699. 

IV.  Disorders  of  Menstruation,  704. — AmenoiThea,  704. — Menorrhagia,  705. 
— Dysmenorrhea,  706. 

V.  Malpositions  of  the  Uterus,  708. — Anteflexion,  708.—  Retro-positions, 
709. — Bimanual  Reposition,  709. — Knee-chest  Reposition,  710. — Alexander's  Ope- 
ration, 712. —  Hysterorrhaphy,  712. — Prolapsus  Uteri,  713. — Inversion  of  the  Ute- 
rus, 714. 

VI.  Inflammation  of  the  Female  Genitals,  715. — Inflammation  of  the  Vulva, 
715.— Vaginitis,  716. — Inflammation  of  the  Uterus,  717. — Acute  Endometritis  and 
Metritis,  718. — Endocervicitis  and  Cervicitis,  719. — Chronic  Endometritis  and  Me- 
tritis, 719. — Chronic  Inflammation  of  the  Body  of  the  Uterus,  723. 

VII.  Pelvic  Inflammation,  724. — Acute  Catarrhal  Salpingitis,  724. — Chronic 
Salpingitis,  725. — Hydrosalpinx,  725. — Hematosalpinx,  726. — Pyosalpinx,  726. — 
Inflammation  of  the  Ovaries,  727. — Acute  Oophoritis,  727. — Chronic  Oophoritis, 
728. — Pelvic  Peritonitis,  728. — Cellulitis,  728. — Chronic  Pelvic  Inflammation,  729. 
— Pelvic  Abscess,  729. — Treatment  of  Pelvic  Inflammations,  730. 

VIII.  Tuberculosis  of  the  Female  Genital  Tract,  733. — Vulva,  Vagina, 
733. — Uterus,   733. — Tubes,  Ovaries,  734. 

IX.  Laceration  of  the  Cervix  Uteri,  735. — Causes,  735. — Diagnosis,  736. — 
Treatment,  736. 

X.  Fibroid  Tumors  of  the  Uterus,  738. — Polypoid  or  Pedunculated 
Fibroids,  738. — Submucous  Fibroids,  739. — Interstitial  fibroids,  739. — Subperi- 
toneal Fibroids,  739. — Treatment,  741. — Alterative,  741. — Electricity,  742. — Sur- 
gical Treatment,  742. — Removal  of  Appendages,  Ligation  of  Uterine  Arteries,  Mor- 
cellation.  Vaginal  Hysterectomy,  Myomectomy,  Abdominal  Hysterectomy,  742. 


CONTENTS.  1 5 


PAGE 


XI.  Uterine  Polypi,  746. — Polypi  of  the  Cervix,  746. — Polypi  of  the  Ute- 
rus, 746. 

XII.  Malignant  Diseases  of  the  Female  Genital  Organs,  747. — Epithe- 
lioma of  the  External  Genitals,  747. —  Sarcoma  of  the  External  Genitals,  748. — 
Sarcoma  of  the  Uterus,  748. — Carcinoma  of  the  Cervix,  749. — Carcinoma  of  the 
Body  of  the  Uterus,  753. — Technique  of  Vaginal  Hysterectomy,  754. — Abdominal 
Hysterectomy  for  Cancer,  with  Removal  of  Part  of  Broad   Ligament,  756. 

XIII.  New  Growths  of  the  Tubes,  Ovaries,  and  Broad  Ligaments,  759. 
— New  Growths  of  the  Tubes,  759. — New  Growths  of  the  Ovaries,  759. — Ovarian 
Cysts,  760. — Ovariotomy,  765. 

XIV.  Extra-uterine  Pregnancy,  766. — Tubal  Pregnancy,  766. — Tubal  Abor- 
tion, 767. — Tubal  Gestation,  767. — Tubo-uterine  Pregnancy,  768. 

CHAPTER   XVII. 
The  X-  (or  Rontgen)  Rays  in  Surgical  Diagnosis 771 

Discovery  of  the  jr-Rays,  771. — Apparatus  Required  for  x-Ray  Work,  778. — 
Uses  of  the  j:-Rays,  780. 

Index 783 


SURGICAL  DIAGNOSIS  AND  TREATMENT. 


CHAPTER    I. 
GENERAL   EXAMINATION    OF    PATIENTS. 

Introduction. — Year  by  year  the  scope  of  surgery  is  expanding, 
and  as  new  territory  is  added  to  his  domain  the  surgeon  must  widen 
his  field  of  inv^estigation.  Until  a  few  years  ago  he  worked  within  a 
narrow  sphere,  and  devoted  about  as  little  time  to  the  study  of  diseased 
conditions  in  the  abdominal,  thoracic,  and  cranial  cavities  as  the  modern 
oculist  gives  to  general  medicine.  All  this  is  changed.  To-day  there 
is  no  organ  of  the  body  beyond  the  legitimate  field  of  surgery,  no  cavity 
whose  innermost  recesses  cannot  be  explored. 

It  is  possible  in  many  surgical  diseases  and  injuries  to  take  in  the 
situation  at  a  glance  and  instantly  to  decide  upon  a  plan  of  treatment ; 
as,  for  example,  in  fractures,  dislocations,  diseases  of  joints,  and  in  cer- 
tain tumors  ;  but  in  the  broader  field  of  modern  surgery  every  known 
method  of  diagnosis  must  be  employed.  A  systematic  and  complete 
examination  of  his  cases  is  therefore  as  necessary  to  the  surgeon  as  to 
the  physician. 

While  the  surgeon's  case-taking  need  not,  as  a  rule,  be  lengthy,  it 
should  be  systematic  and  comprehensive.  The  discovery  of  one  dis- 
ease or  injury  should  not  end  the  investigation.  Every  organ  and 
system  should  pass  under  review,  so  that  there  shall  be  no  possibility 
of  any  important  point  being  overlooked. 

To  the  student  or  the  young  practitioner  the  formation  of  a  habit 
of  recording  his  cases  in  this  manner  will  prove  invaluable.  By  it  he 
trains  his  powers  of  observation,  collects  material  from  which  he  can 
draw  conclusions,  and,  most  important  of  all,  avoids  errors  into  which 
many  of  his  seniors  have  fallen. 

It  cannot  be  denied  that  the  wider  application  of  operative  pro- 
cedures increases  these  dangers.  To  operate  upon  a  pyosalpinx,  and 
afterward  to  find  that  the  patient  is  not  benefited  owing  to  the  existence 
of  long-standing  tuberculosis  in  the  lung,  may  be  a  triumph  in  tech- 
nique, but  it  is  a  blunder  in  diagnosis.  It  is  sadly  disappointing,  when 
a  patient  submits  to  clamp  and  cautery  for  the  relief  of  hemorrhoids, 
to  find,  a  few  weeks  later,  that  his  days  are  drawing  to  a  close  by 
reason  of  a  carcinomatous  liver,  which  existed  but  was  not  thought  of 
at  the  time  of  the  operation.  None  but  those  who  have  suffered  thereby 
can  realize  what  it  is  to  have  treated  a  fracture  of  the  humerus  and  to 
be  confronted  months  afterward  with  a  dislocation  at  the  elbow  that 
was  overlooked  at  the  first  examination. 

2  17 


1 8  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

In  the  diagnosis  of  an}-  surirical  disease  or  injur}' a  decision  must  be 
arrived  at  by  two  lines  of  evidence — that  derived  from  the  patient  or 
the  friends  of  the  patient,  and  tliat  obtained  by  the  surgeon's  own 
objective  examination. 

Information  Obtained  from  the  Patient  or  his  Friends. — 
No  matter  how  clear  a  case  ma}'  api)car  or  how  urgent  the  demand 
for  our  assistance,  we  should  not  neglect  this  part  of  our  examina- 
tion. If  called  to  a  case  of  fracture,  do  not  immediately  begin  to 
manipulate  the  injured  limb.  While  removing  your  overcoat  or 
gloves  it  is  easy  to  inquire  how  the  accident  happened  or  in  what 
position  the  patient  was  standing  or  lying  when  he  was  injured.  A 
few  questions  of  this  character  will  elicit  information  which  may  influ- 
ence your  examination  and  prove  helpful  in  the  diagnosis.  For 
example,  a  fall  upon  the  outstretched  hands  is  apt  to  produce  Colles's 
fracture,  or  upon  the  shoulder  fracture  of  the  clavicle,  or  upon  the 
knee — with  a  strong  effort  on  the  part  of  the  patient  to  save  himself — 
fracture  of  the  patella.  A  history  of  an  injury  caused  by  jumping  from 
a  rapidly-moving  railway  or  street  car  and  landing  upon  the  feet  excites 
our  suspicion  that  a  fracture  of  the  fibula  has  been  sustained. 

In  every  case  the  following  points  should  be  noted  under  the  head- 
ing of  history :  Name  ;  address  ;  occupation  ;  age  ;  sex  ;  family  history  ; 
heredity;  habits,  etc. ;  previous  residences;  former  diseases  or  injuries 
and  results  ;  previous  operations. 

1.  Age  has  an  important  bearing  upon  our  examination.  Sarcoma 
attacks  persons  of  all  ages,  but  particularly  young  people.  Carcinoma 
is  exceedingly  rare  before  thirty  years  of  age,  and  common  after  forty. 
Tuberculosis  of  bones  and  joints  is  most  common  in  childhood.  In- 
flammation of  joints  in  children  is,  in  nearly  all  cases,  an  osteitis,  while 
in  adults  it  not  uncommonly  begins  as  a  synovitis.  Goiter  rarely 
occurs  before  the  ninth  year. 

2.  Heredity. — Our  ideas  on  the  question  of  heredity  have  undergone 
considerable  change.  Formerly  it  was  supposed  that  a  tubercular 
child  must,  almost  of  necessity,  be  the  offspring  of  tubercular  parents. 
While  Baumgarten  asserts  that  it  arises  more  frequently  by  inheritance 
than  in  any  other  way,  the  general  opinion  at  present  is  that,  although 
the  bacillus  may  undoubtedly  be  transmitted  from  parent  to  offspring, 
the  more  frequent  result  of  heredity  is  only  a  predisposition  to  the  dis- 
ease. In  other  words,  the  child  of  tubercular  parents  rarely,  if  ever, 
inherits  the  disease ;  he  is  more  likely  to  acquire  it  when  exposed  to 
the  bacillus  tuberculosis. 

Syphilis  is  a  disease  in  which  heredity  plays  a  most  important  part. 
The  poison  can  be  transmitted  through  the  ova  and  spermatozoa,  so 
that  the  characteristic  lesions  make  their  appearance  before  or  shortly 
after  birth.  It  must  also  be  borne  in  mind  that  the  disease  can  be  thus 
transmitted  long  after  the  power  is  lost  of  communicating  it  by  direct 
contact. 

Cancer  is  not  now  believed  to  be  so  markedly  hereditary'  as  was 
formerly  supposed,  although  its  tendency  to  run  m  families  cannot  be 
denied.  It  would  appear  that  races  and  nationality  have  an  influence 
upon  heredity.  The  whites  of  the  Southern  States  are  more  than  twice 
as  liable  to  cancer  as  the  negroes  of  the  same  region.     The  tendency 


GENERAL   EXAMIXATION  OF  PATIENTS.  1 9 

to  tuberculosis,  on  the  other  hand,  is  greater  in  the  negro  than  in  the 
white.  Jews  are  less  liable  than  other  whites  to  cancer  and  consump- 
tion, but  they  are  specially  liable  to  diabetes  and  to  certain  degenera- 
tions of  the  spinal  cord  in  their  declining  years. 

In  examining  for  the  evidence  of  heredity  the  patient  should  be 
questioned  concerning  the  health  of  his  parents,  brothers,  sisters,  aunts, 
and  uncles.  It  occasionally  happens  that  an  hereditary  disease  skips 
over  a  generation  (atavism) ;  hence  we  must  inquire  into  the  histor)'  of 
the  grandparents  on  both  sides. 

3.  Sex. — Apart  from  diseases  peculiar  to  each  sex,  there  are  certain 
surgical  diseases  and  injuries  which,  although  common  to  both,  show 
marked  preference  for  the  one  or  the  other.  Cancer  is  more  common 
in  females,  owing  to  the  frequencv  with  which  it  attacks  the  mamma 
and  the  uterus.  Sarcoma  is  more  frequent  in  males,  from  the  fact  that 
they  are  more  exposed  to  blows  and  other  traumatic  causes  which  so 
often  precede  sarcomata.  The  same  rule  applies  to  fractures.  Goiter 
is  much  more  frequent  in  women. 

4.  The  manner  of  living,  habits,  occupation,  ability  to  endure  fatigue, 
residence,  and,  in  the  case  of  women,  whether  married  or  single,  also 
the  number  of  children,  if  any, — all  of  these  are  important  points  in 
evidence  upon  which  we  must  return  a  verdict. 

In  the  matter  of  living,  the  diet,  habitation,  hygienic  surroundings, 
and  the  clothing  must  be  taken  into  account.  The  appetites,  the  use 
of  alcohol  and  tobacco,  venereal  excesses,  and  other  abuses  play  an 
important  part. 

Previous  residences  must  be  noted.  Natives  of  Iceland  are  liable  to 
echinococcus  ;  residents  of  tropical  countries  are  liable  to  abscess  of 
the  liver.  Certain  districts  are  conducive  to  goiter,  and  others  to  cal- 
culus of  the  bladder.  Sterility  in  either  sex  and  miscarriages  in  females 
create  a  suspicion  of  syphilis,  while  the  puerperal  period  in  itself  may  be 
a  source  of  grave  disease,  as,  for  instance,  extra-uterine  pregnane}',  in 
the  treatment  of  which  some  of  the  brightest  victories  of  modern 
surgery  have  been  won. 

Many  cases  of  sarcoma  can  be  traced  back  to  a  fracture  or  other 
traumatism.  Brain-abscess  or  blood-clot  or  epilepsy  may  manifest  its 
presence  weeks  or  months  after  the  receipt  of  a  blow  which  caused 
fracture  of  the  skull. 

History  of  the  Present  Disease  or  Injury. — The  patient  or  his 
friends  should  be  required  to  give  the  particulars,  as  far  as  they  can.  of 
the  present  disease  or  injur}',  the  manner  in  which  the  first  departure 
from  health  was  felt,  and  the  circumstances  under  which  an  accident 
occurred,  the  direction  and  force  of  a  missile,  and  the  position  of  the 
body  of  the  injured  person  at  the  time  of  the  accident.  In  cases  which 
are  at  all  likely  to  come  into  court  these  points,  although  apparently 
insignificant,  should  receive  close  attention,  as  they  may  attain  great 
prominence  during  the  trial. 

Examination  of  the  Patient. — Having  noted  down  the  infor- 
mation which  can  be  obtained  from  the  patient  or  his  friends,  the  sur- 
geon next  devotes  himself  to  a  systematic  examination  of  the  case. 
This  is  done  under  two  heads:    i.  General;   2.  Special. 

General  Examination. — Under  this  heading  will  be  comprised 


20  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

(i)  the  general  appearanee  of  the  patient — whether  emaciated  or  well- 
nourished,  well-developed  or  deformed ;  the  condition  of  his  mind — 
whether  calm,  excited,  depressed,   delirious,  etc. 

(2)  The  Position  of  the  Patient. — Much  valuable  testimony  may  be 
obtained  by  noting  the  position  which  the  patient  assumes  while  lying 
in  bed.  A  person  in  good  health  or  only  slightly  ill  will  naturally  lie 
upon  his  back  or  in  an  easy  posture  on  one  or  other  side.  In  a  state 
of  great  weakness  or  when  consciousness  is  impaired  the  patient  is 
inclined  to  slide  down  toward  the  foot  of  the  bed.  Dyspnea  induces  a 
person  to  maintain  a  sitting  posture,  while  inflammation  of  the  lungs 
or  pleura  causes  him  to  lie  in  the  posture  which  gives  most  steadiness, 
usually  upon  the  affected  side.  In  peritonitis  the  sufferer  lies  on  his 
back  with  the  limbs  drawn  up,  and  cannot  even  bear  the  weight  of  the 
bed-clothes.  In  cerebral  meningitis  the  head  is  drawn  backward,  bur- 
rowing, as  it  were,  into  the  pillow.  In  localized  inflammation  of  the 
brain  the  head  is  persistently  held  to  one  side.  When  the  cerebellum 
or  crura  cerebelli  are  the  seat  of  disease,  it  is  not  uncommon  to  see  the 
whole  body  drawn  sharply  to  one  side,  and  immediately  returning  to 
this  position  if  disturbed. 

(3)  Surface-markings  and  Changes  of  Contour. — Under  this  head 
will  be  noted  any  scars,  deformities,  changes  in  the  shape  of  limbs,  etc. 
It  will  embrace  tumors,  deformities  from  old  or  recent  fractures, 
dislocations,  etc. 

(4)  The  Condition  of  the  Skin. — {a)  Color :  Redness  may  be  due  to 
hyperemia,  by  w^hich  is  meant  an  increase  of  the  quantity  of  blood  in 
the  vessels  of  the  part,  or  to  an  escape  of  blood  from  the  vessels 
(extravasation.)  It  is  a  very  simple  matter  to  decide  which  of  these 
conditions  is  producing  the  redness.  Light  pressure  will  empty  the 
vessels  in  hyperemia  and  cause  a  momentary  paleness ;  upon  extrav- 
asations or  purpura  pressure  has  no  effect. 

Besides  paleness  or  redness,  certain  modifications  of  color  are 
deserving  of  notice.  One-sided  redness  of  the  face  indicates  localized 
vasomotor  paralysis  and  is  suggestive  of  hemicrania.  A  characteristic 
sallow  hue  }\\th  shiny  appearance  is  given  to  the  skin  in  sudden  and 
severe  hemorrhage.  Prof  Syme  was  in  the  habit  of  drawing  our 
attention  to  the  peculiar  appearance  of  the  faces  of  those  who  suffered 
repeated  loss  of  blood  from  hemorrhoids.  Cyanosis,  or  blue-red  skin, 
is  due  to  an  accumulation  of  carbonic  acid  and  a  deficiency  of  oxygen 
in  the  capillaries.  It  arises  in  connection  with  disturbed  respiration 
and  circulation  through  the  lungs.  It  may  also  occur  in  the  greater 
circulation,  and  be  either  general  or  local  according  to  the  extent  of 
obstruction.  Cyanosis  is  seen  in  the  following  conditions :  spasm  of 
the  glottis ;  tumors  of  the  larynx ;  acute  and  chronic  inflammation  of 
the  larynx  or  trachea ;  foreign  bodies  in  the  air-passages ;  goiter  or 
other  tumors  which  press  upon  the  larynx  or  trachea ;  mediastinal 
tumors ;  bronchitis ;  aneur}^'sm  of  the  aorta ;  and  in  any  condition 
which  prevents  complete  expansion  of  the  lungs,  such  as  pleuritic  or 
pericardial  effusion,  thoracic  tumors,  and  peritonitis  w^hen  it  produces 
paralysis  of  the  diaphragm,  etc. 

The  yellow  or  jaundiced  or  icteric  skin  is  of  interest  to  us  in  the 
surgery  of  the  liver  and  gall-bladder.     It  is  not,  as  a  rule,  an  indication 


GENERAL   EXAMINATION  OF  PATIENTS.  21 

of  abscess  of  the  liver ;  in  fact,  its  existence  may  be  said  to  be  an 
argument  against  the  diagnosis  of  abscess. 

Obstruction  in  the  hepatic  duct  or  the  common  bile-duct  produces 
jaundice,  while  obstruction  in  the  cystic  duct  does  not.  One  of  the 
most  common  causes  is  the  presence  of  gall-stones.  It  may  also  be 
produced  by  any  tumors  which  press  upon  the  duodenal  orifice  of  the 
ductus  communis  choledochus,  and  especially  cancer  of  the  head  of  the 
pancreas.  A  practical  point  worth  remembering  is  that  jaundiced 
patients  bleed  more  freely  during  operations  than  do  others. 

Scars  are  especially  worthy  of  notice,  but  in  no  location  are  they  so 
important  as  on  the  scalp.  A  scalp  wound  dressed  in  the  drug-store 
style,  with  no  regard  for  asepsis,  may  heal,  to  all  appearance,  in  a  satis- 
factory^ manner,  but  at  the  same  time  germs  may  find  their  way  through 
the  skull  along  the  vessel-channels  and  lead  to  cerebral  abscess  later  on. 

(5)  Tevipcratiirc. — High  temperature  is  present  in  fever,  inflamma- 
tory disease,  and  some  nervous  conditions.  It  is  important  as  indi- 
cating the  absorption  of  septic  material  from  a  wound  or  pus-cavity, 
and  is  a  reliable  indication  for  a  removal  or  change  of  dressings.  After 
operations  of  any  magnitude  there  is  during  the  first  forty-eight  hours 
a  rise  of  temperature  known  as  fermentation  or  aseptic  fever,  which 
may  reach    102°   F.,  without  exciting  any  uneasiness. 

Subnormal  temperatures  occur  temporarily  in  severe  hemorrhages, 
in  chronic  diseases  of  the  heart  and  lungs,  and  in  most  chronic  wasting 
diseases.  A  sudden  fall  of  temperature,  accompanied  by  weakness  of 
the  heart  and  general  prostration,  is  spoken  of  as  collapse.  Continued 
low  temperature  is  rare,  but  it  may  be  found  in  abscess,  in  inflamma- 
tion of  the  brain,  and  in  some  wasting  diseases.  In  acute  alcoholism 
the  temperature  has  been  observed  as  low  as  75"^  F. 

Local  Changes  in  Temperature. — A  local  increase  in  temperature  is 
indicative  of  inflammation  or  paralysis  of  the  vasomotor  nerves  of  the 
part.  A  lowered  temperature  is  indicative  of  disturbance  of  the  circu- 
lation. It  is  commonly  found  in  venous  thrombosis.  In  paralysis  of 
a  nerve  the  local  temperature  is  usually  first  increased  and  afterward 
diminished. 

The  knowledge  gained  by  the  general  examination  will* point  to  one 
or  more  of  the  special  organs  or  systems  of  the  body  as  the  seat  of 
the  disease.  The  examination  will  be  continued  by  making  a  minute 
and  careful  study  of  the  special  system  or  organ  to  which  the  symp- 
toms so  far  point.  Having  exhausted  that  part,  the  other  systems  and 
organs  are  systematically  examined.  Our  special  study,  therefore,  will 
comprise — 

1.  The  Vascular  System  ; 

2.  The  Osseous  System  ; 

3.  The  Joints  ; 

4.  The  Digestive  System  ; 

5.  The  Genito-urinary  System; 

6.  The  Nervous  System  ; 

7.  The  Respiratory  System  ; 

8.  Morbid  Growths  ; 

9.  The  Female  Generative  Organs. 


22  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

CHAPTER    II. 
EXAMINATION    OF    THE    VASCULAR   SYSTEM. 

I.  THE   HEART   AND  PERICARDIUM. 

Having  removed  the  patient's  clothing  so  as  to  expose  the  chest, 
the  student  will  find  it  useful  to  begin  by  counting  the  ribs.  The 
novice  may  have  a  little  difficulty  in  distinguishing  the  first  rib.  It  is 
covered  in  its  outer  half  by  the  clavicle,  but  near  the  sternum  it  lies 
below  the  clavicle.  Follow  the  front  of  the  sternum  from  its  notch 
downward.  About  \\  inches  from  the  suprasternal  notch  the  fingers 
will  feel  a  ridge  on  the  bone.  This  is  the  junction  of  the  manubrium 
with  the  gladiolus,  and  is  exactly  opposite  to  the  insertion  of  the 
second  rib.  Having  definitely  settled  the  location  of  either  the  first  or 
second  rib,  it  is  an  easy  matter  to  count  downward.  (Mark  with  your 
pencil  the  third  costal  cartilage  on  the  right  side  and  the  sixth  costal 
cartilage  on  the  left  side :  these  points  represent  the  upper  and  lower 
limits  of  the  heart  in  the  healthy  chest.) 

Now  mark  a  point  half  an  inch  to  the  right  of  the  sternum,  and 
another  point  half  an  inch  to  the  right  of  the  left  nipple,  and  you  have 
the  horizontal  limits  of  the  heart.  The  right  auricle  lies  behind  the 
cartilage  of  the  third  rib  on  the  right  side,  and  the  left  auricle  behind 
the  third  costal  cartilage  on  the  left  side.  Posteriorly  the  heart-dulness 
is  found  between  the  fourth  and  eighth  dorsal  spines.  The  left  auricle  is 
covered  by  the  pulmonary  artery.  The  right  ventricle  is  partly  behind 
the  sternum  and  partly  to  the  left  of  it.  Behind  the  right  lies  the  left 
ventricle,  except  a  small  portion  at  its  apex. 

The  pericardium  is  the  fibro-serous  sac  which  contains  the  heart  and 
the  portions  of  the  great  vessels  which  enter  into  or  issue  from  its  base. 
It  is  attached  above  to  the  deep  cervical  fascia,  and  below  (which  is  its 
widest  part)  it  is  in  connection  with  the  diaphragm. 

Two  conditions  of  the  heart  which  call  for  surgical  interference  are — 
overdistention  of  the  ventricles  and  effusion  into  the  pericardium. 

Overdistention  of  the  Ventricles. — This  occurs  in  acute  pul- 
monary congestion.  When  the  lung-tissue  in  a  violent  onset  of  acute 
inflammation  becomes  engorged  with  blood  and  the  air-cells  are  filled 
with  exudation,  the  blood  is  forced  with  difficulty  through  the  pul- 
monary circulation,  the  right  ventricle  becomes  overdistended,  and, 
unless  relief  is  obtained,  the  condition  becomes  critical.  The  symp- 
toms indicating  overdistention  are — great  dyspnea,  dulness  on  percus- 
sion over  a  considerable  area  of  one  or  both  lungs,  vocal  fremitus,  and 
distress  over  the  region  of  the  heart. 

In  the  treatment  of  this  dangerous  condition  the  heart  may  be 
relieved  of  a  portion  of  its  blood  and  the  distention  lessened  by  tap- 
ping its  cavity.  The  most  convenient  method  of  doing  this  is  to  aspi- 
rate the  right  auricle.  Find  the  third  interspace,  and  at  a  point  close 
to  the  right  of  the  sternum  insert  the  needle.  The  reasons  for  select- 
ing the  right  auricle  are — first,  the  wall  is  thinner  than  that  of  the  ven- 
tricles ;  second,  it  has  a  greater  antero-posterior  diameter ;  third,  it  is 
least  liable  to  change  its  position  in  relation  to  sun'ounding  parts. 


EXAMINATION   OF   THE    VASCULAR  SYSTEM.  23 

Operation. — Sterilize  the  skin  and  instruments.  Use  a  large-sized 
aspirating  needle  attached  to  the  tube  of  an  aspirator,  for  the  force  of 
the  circulation  is  not  sufficient  to  drive  the  blood  through  the  needle. 
The  needle  should  be  pushed  directly  backward  until  it  enters  the 
cavity,  and  the  operation  should  be  performed  as  quickly  as  possible. 
It  is  attended  with  great  danger.  I  question  whether  it  possesses  any 
advantages  over  the  old  method  of  bloodletting,  which  is  attended  with 
very  happy  results  in  just  such  cases. 

Effusion  into  the  Pericardium. — Under  normal  conditions  the 
fluid  which  lubricates  the  inner  surface  of  the  pericardium  is  in  the 
form  of  vapor,  thus  allowing  the  heart  to  beat  with  the  least  possible 
friction  or  impediment  to  its  movements.  In  pericardial  effusion  these 
favorable  conditions  are  lost,  and  the  laboring  heart  is  compelled  to  do 
its  work  in  a  pool  of  watery  fluid. 

In  nearly  every  instance  effusion  into  the  pericardium  is  a  sequel  of 
rheumatic  fever.  The  symptoms  are  dyspnea,  great  distress  in  the  pre- 
cordia :  as  a  patient  once  expressed  herself  to  me,  "  The  heart  feels  as 
if  it  were  bursting."  The  area  of  dulness  is  much  increased,  and  may 
extend  as  high  as  the  clavicle.  The  dull  area  is  generally  pyriform  or 
quadrilateral  in  shape,  with  the  base  below  and  extending  to  both  sides 
of  the  apex  of  the  heart.  The  movements  of  the  left  chest  are  im- 
paired, the  veins  of  the  neck  are  enlarged,  and  a  peculiar  wavy  motion 
is  felt  when  the  hand  is  placed  over  the  heart.  The  apex-beat  is  felt 
higher  up  than  in  the  normal  condition,  and  to  the  left.  By  the  stetho- 
scope we  find  muffling  of  the  heart-sounds  and  the  absence  of  vocal 
resonance  and  fremitus.  If  we  examine  the  case  before  the  pericardial 
walls  become  separated  from  one  another  by  the  fluid,  we  may  find  a 
pericardial  friction-sound.  This  sound  is  not  propagated  beyond  the 
pericardium,  and  is  wanting  in  the  regularity  of  rhythm  which  charac- 
terizes the  endocardial  murmur. 

Many  cases  of  effusion  are  slight  and  have  a  tendency  to  end  in 
absorption.  In  exceptional  cases,  however,  the  fluid  increases  and 
threatens  life.  Then  we  should  unhesitatingly  resort  to  the  operation 
of  paracentesis  of  the  pericardium. 

In  the  left  fifth  interspace  mark  with  a  pencil  a  spot  2  inches  to  the  left 
of  the  left  border  of  the  sternum.  This,  as  a  rule,  is  the  best  point  at 
which  to  aspirate  the  pericardium.  The  reasons  for  selecting  this  posi- 
tion are — (i)  it  gets  at  the  fluid  in  the  lowest  part  of  the  pericardial 
cavity,  thus  securing  perfect  drainage ;  and  (2)  this  point  is  well  to  the 
outside  of  the  internal  mammary  artery. 

Operation. — Use  a  good-sized  needle  and  aspirator.  Push  the 
needle  directly  backward  until  the  cavity  is  reached ;  withdraw  the 
trocar  quickly,  leaving  the  cannula  in  position,  so  as  to  avoid  puncturing 
the  heart-muscle.     Draw  off  the  fluid  slowly  and  watch  the  effect. 

In  the  case  of  a  lady  upon  whom  I  thus  operated  the  opening  was 
made  in  the  sixth  interspace,  because  the  enormous  amount  of  fluid 
which  was  present  distended  the  sac  much  below  the  usual  limits.  The 
heart  touched  the  cannula  at  every  pulsation.  The  patient  fainted 
several  times  during  the  operation.  Thirty-two  ounces  of  serum  were 
withdrawn,  and  a  good  recovery  was  the  result. 

When  the  fluid  is  found  to  be  purulent  the  proper  treatment  is  to 


24  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

make  an  incision  and  employ  drainage.  Therefore,  while  the  cannula 
is  still  in  position  and  pus  is  found  to  escape,  use  the  cannula  for  a 
<^uide,  dissectini:^  carefully  through  the  tissues  until  the  finger  can  enter 
the  pericardial  cavity.  If  sufficient  room  cannot  be  obtained  or  if  the 
drainage-tube  cannot  be  kept  open,  it  will  be  necessary  to  remove  a 
portion  of  a  rib.  The  pericardium  bears  washing  out  and  disinfecting 
well,  and  is  tolerant  of  mechanical  and  chemical  irritations. 

Injuries  of  the  Heart. — Rupture  of  the  heart  is,  fortunately, 
rare.  It  has  been  known  to  occur  as  a  result  of  a  thrombus  or  an 
embolus  causing  complete  obstruction  in  one  of  the  branches  of  the 
coronary  arteries.  A  sudden  rupture  of  an  aneurysm  or  an  abscess 
into  one  of  the  cardiac  cavities  has  produced  rupture.  It  has  also  been 
noted  as  a  cause  of  death  in  tetanus.  The  onset  of  the  symptom  is  so 
sudden  and  so  fatal  as  to  leave  little  for  us  to  study  in  the  way  of 
diagnosis. 

Wounds  of  the  Heart. — The  circumstances  under  which  we 
would  expect  to  find  wounds  of  the  heart  are — violent  compression 
of  the  thorax,  fracture  of  the  sternum  and  costal  cartilages,  with  frag- 
ments driven  inward,  or  wounds  from  the  outside,  such  as  stabs  or 
gunshot  injuries.  The  organ  has  also  been  wounded  by  fishbones  or 
other  foreign  bodies  penetrating  it  from  the  esophagus. 

A  wound  of  the  heart  does  not  necessarily  occasion  death.  Strange 
as  it  may  at  first  appear,  a  stab  wound  penetrating  this  organ  may  be 
followed  by  little  or  no  hemorrhage.  This  is  due  to  the  peculiar 
arrangement  of  the  fibers  of  the  cardiac  muscles.  In  examining  the 
heart  for  wounds  we  must  be  guided  by  the  following  symptoms  :  Pain 
is  felt,  and  it  is  usually  severe,  but  may  be  absent  owing -to  collapse. 
In  most  cases  there  is  syncope.  If  there  be  escape  of  blood  into  the 
pericardium,  we  will  find  the  area  of  cardiac  dulness  enlarged,  owing 
to  the  presence  of  the  fluid.  At  the  same  time,  the  heart-sounds  will 
be  less  distinct,  and  in  certain  cases  splashing  may  be  heard.  A  sign 
of  pericardial  hemorrhage  is  dyspnea. 

Treatment. — The  patient  should  be  kept  at  perfect  rest,  with  the 
head  lowered  to  avert  anemia  of  the  brain,  and  opium  may  be  given  to 
relieve  pain  and  shock.  Unless  the  hemorrhage  from  the  external 
wound  be  copious  and  of  itself  threatening  life,  it  is  best  not  to  check 
it,  lest  the  flow  take  place  into  the  pericardium  and  cause  death  by  its 
presence  there. 

II.    EXAMINATION  OF  THE   VEINS. 

The  morbid  conditions  of  veins  which  are  interesting  from  a  surgical 
point  of  view  are — Wounds,  TJirovibosis,  Phlebitis,  Varix  or  ]^arieose 
Veins,  and  Nevus.  The  examination  is  made  by  inspection,  and  some- 
times by  palpation  and  auscultation. 

Wounds  of  Veins. — When  a  small  vein  is  wounded  it  collapses 
and  hemorrhage  from  it  is  slight.  A  wound  of  a  large  vein  is  attended 
with  great  danger,  owing  to  the  rapidity  with  which  the  blood  escapes 
from  it.  Besides  this  danger,  most  serious  consequences  can  arise  from 
septic  infection.  The  symptoms  of  venous  hemorrhage  are — a  steady 
flow  of  dark-colored  blood,  being  in  marked  contrast  to  the  light-red 


EXAMINATION  OF   THE    VASCULAR   SYSTEM.  25 

color  and  spirting  of  the  blood  from  an  artery ;  pressure  on  the  distal 
side  of  the  vein  causes  arrest  of  hemorrhage,  while  pressure  on  the 
proximal  side  increases  it. 

Treatvioit. — In  small  veins  perfect  rest  of  the  part,  elevation  of  the 
limb,  and  pressure  on  the  distal  side  are  all  that  are  necessar}'.  When 
large  veins  are  wounded  the  divided  ends  should  be  found  and  secured 
with  aseptic  catgut  ligatures.  A  longitudinal  slit  in  a  large  vein  can 
sometimes  be  closed  by  picking  it  up  with  forceps  and  securing  the 
bleeding  point  with  a  ligature,  without  obstructing  the  lumen  of  the 
vessel.  If  the  longitudinal  slit  in  the  vein-wall  is  too  long  to  be 
grasped  by  forceps  and  ligated,  it  is  possible  to  close  it  by  a  fine  con- 
tinuous silk  or  catgut  suture.  It  is  not  necessar)'  that  a  clot  should 
form  at  the  point  of  ligation. 

Thrombosis. — In  its  normal  state  a  vein  is  a  soft,  unresisting  tube. 
The  superficial  vessels  are  readily  seen  and  felt,  while  the  deeper  are 
beyond  observ^ation.  When  thrombosis  takes  place  all  this  is  changed. 
The  veins  become  transformed  into  hard,  knotted  cords,  and  some  of 
the  deep  as  well  as  the  superficial  can  readily  be  felt  beneath  the 
examining  fingers.  Thrombosis  is  due  to  some  alteration  in  the  wall 
of  the  vessel,  to  changes  in  the  blood,  or  to  both  causes  combined. 
We  look  for  it  in  parts  where  the  circulation  is  most  feeble,  as,  for 
instance,  in  varicose  veins  or  behind  valv^es.  In  exhausting  diseases, 
such  as  typhoid  fever  or  advanced  phthisis,  clots  often  form  very 
insidiously,  without  any  apparent  change  in  the  vessel-walls.  Foreign 
bodies  introduced  into  the  lumen  of  a  v^essel  produce  clots  in  a  short 
time,  and  this  circumstance  is  made  use  of  in  the  treatment  of  aneurysm. 
The  tendency  of  venous  thrombi  is  to  extend  toward  the  heart,  spread- 
ing from  vein  to  vein.  The  danger  comes  when  the  clot  reaches  a 
vessel  in  which  the  current  is  too  rapid.  A  portion  of  the  thrombus  is 
liable  to  break  off,  and,  being  swept  into  the  current  of  the  circulation, 
sooner  or  later  becomes  impacted  in  a  vessel  and  constitutes  an  embolus. 

Phlebitis,  or  inflammation  of  v^eins,  has  the  knott}^  cord-like  cha- 
racter just  described,  but  in  addition  there  is  acute  inflammation  of 
the  surrounding  cellular  tissue  (Fig.  i).  The  affected  part  is  very  tender 
to  the  touch,  and  at  times  the  skin  is  reddened.  There  is  usually  con- 
siderable pain  and  stiffness,  particularly  on  movement,  and  the  discom- 
fort is  increased  by  allowing  the  limb  to  hang  down.  The  limb  is  stiff, 
heavy,  and  unwieldy.  When  the  deep  veins  of  the  leg  are  inflamed, 
there  is  usually  edema  about  the  ankle  due  to  interference  with  the 
return  circulation. 

The  treatment  includes  rest,  elevation  of  the  limb,  cold,  acetate-of- 
lead  lotion,  mild  cathartics,  light  diet,  and  the  proper  treatment  for  the 
diathetic  disease  which  may  be  the  cause,  such  as  gout^  syphilis,  or 
rheumatism.  If  there  is  a  tendency  to  the  formation  of  abscess,  use 
warm  antiseptic  baths,  and  as  soon  as  practicable  get  rid  of  the  pus  by 
incision. 

Varix,  or  varicose  veins,  are  easily  diagnosticated.  They  are 
usually  found  in  the  lower  extremity ;  and  the  vein  most  commonly 
involved  is  the  internal  saphenous.  The  vessels  are  dilated,  thick- 
ened, tortuous,  and  rise  above  the  level  of  the  skin.  Sometimes  the 
varicose  condition  begins  where  the  veins  take  their  origin  from  the 


26 


Si'KGJCAL   DIAGNOSIS  AND    TREATMENT. 


CiH)illaiy  s)'stcm.    When  such  is  the  case  the  part  shows  a  fine  capilhuy 
injection  with  an  arborescent  appearance. 

We  at  other  times  find  the  limb  presenting  a  marble-like  character, 
hard  and  swollen,  but  not  pitting  on  pressure.  This  is  apt  to  take  on 
an  eczema  of  the  skin,  which  later  forms  ulcers — the  so-called  varicose 
ulcers.     The  danger  attending  varicose   veins,  and  more  particularly 


l'"u;.  I. — Phlebitis  of  the  lower  extremities  in  a  child. 


where  ulceration  is  superadded,  is  the  liability  to  bursting  of  the  veins 
and  inevitable  hemorrhage.  A  varicose  vein  cannot  readily  be  mistaken 
for  anything  else.  It  is  possible,  however,  that  a  varix  of  the  internal 
saphenous  may  be  mistaken  for  femoral  hernia.  The  point  is  easily 
settled.  When  the  patient  lies  down  the  varicose  tumor  disappears ; 
so  does  a  femoral  hernia.  Ask  the  patient  to  cough  or  assume  the 
upright  position  ;  both  swellings  reappear.  But  press  upon  the  swell- 
ing while  the  patient  is  in  the  recumbent  position,  then,  still  keeping  up 
the  pressure,  ask  him  to  stand  up ;  if  the  swelling  is  a  varix,  it  will 
reappear ;  if  a  hernia,  it  will  not. 

Varicose  veins  are  produced  by  two  conditions  acting  simultaneously  : 
first,  increased  local  blood-pressure  and  obstruction  of  the  return  cir- 
culation, and  second,  a  specific  pathological  condition  not  yet  satis- 
factorily explained.  The  commonest  causes  are  tumors  in  the  pelvis, 
pregnancy,  diseases  of  the  heart  and  lungs,  and  occupations  which 
require  the  person  to  stand  long  upon  his  feet.  Obstruction  or  defect- 
ive development  of  the  vena  cava  is  capable  of  producing  varicose  veins 
of  enormous  extent,  as  was  shown  in  a  case  reported  by  Dr.  Derville. 

Treatment. — Palliative. — Remove  the  cause  by  attention  to  the 
bowels  and  by  treatment  of  the  disease  which  has  produced  obstruc- 
tion in  the  veins.  Much  benefit  can  be  obtained  by  wearing  an  elastic 
bandage   or  stocking.      Bandages   of   zinc   glue  are    cheap  and   very 


EXAMINATION   OF  THE    VASCULAR  SYSTEM.  2/ 

serviceable.  They  are  applied  as  follows :  A  gauze  roller  bandage  is 
first  applied  to  the  leg,  and  over  this  a  layer  of  the  glue,  at  a  tem- 
perature sufficient  to  keep  it  fluid,  is  applied  with  a  brush.  After  a 
few  minutes  another  layer  of  bandage,  followed  by  a  second  coating 
of  glue,  completes  the  dressing.  The  limb  is  kept  at  rest  for  an  hour 
to  allow  the  bandage  to  dry.  After  dissolving  the  zinc  glue  the  vessel 
containing  it  should  be  left  floating  in  hot  water  to  prevent  cooling. 

Radical  measures  include  the  following :  Exposure  and  ligation  of 
the  vein,  subcutaneous  section  with  compression,  multiple  subcutaneous 
ligatures,  injections  of  pure  carbolic  acid  into  the  tissues  about  the 
veins,  the  use  of  acupressure  needles  and  twisted  sutures,  and  excision 
of  more  or  less  of  the  diseased  vein. 

Nevus,  telangiectasis,  or  mother's  mark,  is  a  disease  affecting 
both  veins  and  capillaries.  Nevi  are  easily  recognized.  Their  most 
common  seat  is  on  the  face,  and  sometimes  on  the  trunk.  In  size 
they  vary  from  a  pin's  head  to  an  area  the  size  of  the  hand  or  even 
larger.  When  the  nevus  is  composed  of  capillaries,  the  growth  is 
raised  slightly  above  the  skin  and  is  of  a  scarlet  or  purple  color.  If 
veins  enter  into  its  formation,  it  is  either  in  the  skin  or  beneath  it.  It 
pulsates  and  is  larger  than  the  capillary  nevus,  and  of  a  blue  color. 
To  this  form  the  name  of  cavernous  angioma  is  sometimes  applied. 
If  one  of  these  growths  be  cut  into  or  punctured,  alarming  hemor- 
rhage is  liable  to  follow. 

Treatment. — Many  operations  have  been  resorted  to  for  the  removal 
of  nevus.  Ligation  and  excision  are  the  best.  Ligation  is  best  em- 
ployed by  passing  a  pin  under  the  growth,  and  then  placing  a  ligature 
below  the  pin  to  constrict  the  whole  mass.  Larger  nevi  require  double 
ligatures,  which  can  best  be  applied  by  passing  a  second  ligature  under 
and  at  right  angles  to  the  pin,  and  tying  the  nevus  in  two  halves. 
Excision  is  very  satisfactory  when  loose  skin  can  be  obtained  to  allow 
the  edges  of  the  wound  to  come  accurately  together  without  puckering 
or  stretching.  Injection  of  coagulating  fluids  and  electrolysis  have  also 
been  employed,  and  good  results  have  followed  in  many  cases.  It 
must,  however,  be  borne  in  mind  that  this  treatment  has  occasionally 
led  to  sudden  death  from  embolism. 

III.  EXAMINATION   OF  THE  ARTERIES. 

Our  inquiries  under  this  head  will  comprise  ivounds  of  arteries, 
rupture  of  arteries,  atheroma,  inflammation  of  arteries,  and  aneurysm. 

In  a  wound  of  any  extent  the  question  of  hemorrhage  is  a  prom- 
inent one.  It  will  be  necessary  to  decide  what  arteries,  if  any,  are 
divided,  and  promptly  check  the  flow  of  blood  from  them.  Blood 
flowing  from  a  divided  artery  is  bright  red  and  comes  in  jerks.  From 
a  vein  it  is  purple  and  has  a  continuous  flow  or  wells  up  out  of  the 
wound.  From  capillaries  bright  red  blood  oozes  out  more  or  less 
freely,  and  there  is  no  spirting. 

There  are  conditions  in  which  the  spirting  of  an  artery  cannot  be 
seen,  as  when  the  divided  vessel  lies  at  the  bottom  of  a  deep  wound 
and  the  blood  wells  up  rapidly.  The  flow  is  then  continuous,  but  its 
persistence  and  profuseness  are  sufficient  evidence  that  a  large  vessel 


28  SCRGICAL    DIAGNOSIS  AND    TREATMENT. 

is  involved.  The  position  of  the  wound  will  indicate  the  arterial  trunk 
or  branch  from  which  the  blood  flows.  The  treatment  will  depend  upon 
the  size  and  position  of  the  vessel,  and  also  upon  the  amount  of  blood 
which  is  escapint^.  In  many  cases  the  natural  arrest  of  hemorrhage  is 
sufficient  (the  contraction  of  the  coats  of  the  vessel  within  the  sheath 
and  the  coagulation  of  the  blood  in  the  divided  ends  of  the  artery),  in 
others  we  must  assist  nature. 

The  readiest  temporary  method  of  arresting  hemorrhage  is  by 
pressure  at  the  bleeding  point  or  upon  the  artery  above  it.  Never  be 
afraid  of  a  bleeding  poi>it  ivlien  yoii  can  plaee  your  finger  npon  it  (not  a 
dirty  but  an  aseptic  finger).  If  you  make  pressure  at  the  proper  spot, 
vcr}'  little  force  is  required,  and  this  force  can  be  easily  maintained 
until  permanent  control  of  the  bleeding  has  been  secured.  Pressure 
upon  the  artery  above  the  wound  is  applied  by  the  fingers,  by  a  tour- 
niquet, or  by  an  Esmarch  bandage.  The  brachial  can  be  controlled  by 
pressure  upon  it  in  the  middle  of  the  arm,  where  it  lies  in  the  angle 
on  the  inner  side  of  the  biceps.  The  subclavian  can  be  controlled  by 
the  thumb  pressing  the  vessel  against  the  first  rib.  The  femoral  at 
Poupart's  ligament  lies  midway  between  the  symphysis  pubis  and  the 
anterior  superior  spinous  process.  It  can  be  compressed  most  readily 
by  the  thumbs  of  the  operator,  who  stands  in  such  a  position  that  his 
arms  are  almost  straight.  This  position  is  not  fatiguing,  and  can  be 
maintained  for  half  an  hour  or  so  without  difficulty.  The  femoral  can 
also  be  compressed  on  the  inner  aspect  of  the  thigh  at  its  entrance  to 
Hunter's  canal.  The  aorta  is  compressed  with  difficulty,  except  in 
children  and  emaciated  people.  It  can,  in  them,  be  felt  just  above  and 
a  little  to  the  left  of  the  umbilicus.  The  radial  and  ulnar  can  be  com- 
pressed just  above  the  wrist,  and  the  tibial  for  a  short  distance  above 
the  ankle. 

Tourniquets  are  necessary  when  continued  compression  is  required. 
The  most  simple  is  Esmarch's,  which  consists  of  a  |-inch  rubber  tube 
about  1 8  inches  in  length,  with  a  hook  at  each  end.  It  is  simply 
wound  around  the  limb  above  the  wound  tight  enough  to  compress 
the  artery.  The  dangers  of  Esmarch's  bandage  are  paralysis  of  nerves 
(by  too  long  compression)  and  anemia.  Sloughing  has  been  produced, 
particularly  when  the  tourniquet  has  been  applied  for  primary  hemor- 
rhage before  amputation.  It  should  be  kept  on  as  short  a  time  as 
possible.  An  emergency  tourniquet  can  be  made  from  a  handkerchief 
tied  around  the  limb  and  twisted  tightly. 

Having  got  the  bleeding  under  control,  the  next  question  is  how  to 
arrest  it  permanently.  The  stoppage  of  the  circulation  by  pressure  or 
the  tourniquet  has  given  the  blood  at  the  bleeding  point  time  to  coagu- 
late, and  if,  when  the  pressure  is  slowly  removed,  no  blood  escapes, 
the  wound  may  be  dressed,  leaving  the  clot  in  position.  When  the 
divided  artery  can  be  seen,  it  should  be  tied  at  both  ends  with  catgut 
or  silk  ligature.  If  the  wound  is  not  large  enough  to  expose  the  ves- 
sel, it  must  be  extended  and  the  bleeding  points  found  and  tied. 

Heat  is  a  valuable  means  of  arresting  hemorrhage  from  a  number 
of  small  vessels  or  oozing  from  a  large  surface.  It  is  best  applied  by 
using  water  as  hot  as  can  be  borne  by  the  hand. 

Cold  is  also  a  good  hemostatic.     It  is  employed  by  exposing  the 


EXAMINATION   OF   THE    VASCULAR   SYSTEM  29 

wound  to  the  air  or  by  ice  or  ice-water.  Its  action  is  upon  the  muscular 
coats  of  the  vessels,  and  is  only  of  value  when  the  bleeding  vessels  are 
small. 

Packing  with  iodoform  gauze  is  required  in  niany  cases,  but  except 
where  it  is  desirable  to  have  the  wound  heal  by  the  open  method,  as  in 
operations  for  the  removal  of  diseased  bone,  it  is  seldom  employed. 

Acute  Arteritis. — This  is  a  rare  disease,  and  some  writers  state 
that  it  is  doubtful  if  it  has  ever  been  diagnosed  during  life.  The  cases 
in  which  tenderness  and  redness  were  observed  along  the  course  of  an 
artery  having  recovered,  there  was  no  opportunity  to  verify  the  diag- 
nosis by  post-mortem.  In  a  case  of  symmetrical  gangrene  which  came 
under  my  care   I  was  able  to  trace  the  radial  arteries  and  the  caro- 


^^^' 


J 


Fig.  2. — Symmetrical  gangrene  without  Raynaud's  phenomena  (Jonatlian  Hutchinson). 

tids  by  the  tenderness  and  hard,  cord-like  feeling,  such  as  is  found 
in  phlebitis,  and  confidently  pronounced  the  condition  acute  arteritis. 
The  patient,  a  little  girl,  died  from  occlusion  of  the  middle  cerebral 
artery.  The  post-mortem  clearly  showed  arteritis  and  an  extension  of 
the  inflammation  from  the  carotid  to  the  arteries  of  the  brain,  which 
caused  her  death. 

The  symptoms  which  are  indicative  of  acute  arteritis  are — tenderness 
along  the  course  of  the  vessel,  a  hard,  cord-like  feeling  under  the 
fingers  when  the  vessel  is  pressed  upon,  and  at  times  obliteration  of 
the  artery,  followed  perhaps  by  gangrene  of  the  parts  to  which  the 
artery  is    distributed. 

Chronic  Arteritis. — This  is  very  important  to  us  from  a  diag- 
nostic point  of  view.  Chronic  arteritis,  or  atheroma  of  the  older 
authors,  is  the  condition  which  lays  the  foundation  for  aneur>^sm.  It  is 
chronic  inflammation  of  the  internal  coat,  with  fatty  degeneration  and 
a  tendency  to  the  formation  of  calcareous  deposits.  We  should  look 
carefully  for  atheromatous  arteries  in   old  people,  in  those  who  have 


30 


SURGICAL    DIAGNOSIS  AXD    TREATMENT. 


suffered  from  rheuniatisni,  l^right's  disease.  L^out,  or  syphilis,  and  in 
hard  drinkers.  We  must  bear  in  mind  that  atheroma  affects  the  large, 
while  s}'philis  attacks  the  smaller,  arteries.  The  disease  begins  in  the 
inner  coat,  which  becomes  opaque  and  cloudy.  The  circulation  in  it  is 
disturbed,  and  in  parts  cut  off,  so  that  ulceration  soon  follows.  The 
middle  coat  does  not  become  involved  until  late,  and  the  outer  coat  is 
affected  last  of  all.  It  is  only  when  atheroma  has  produced  its  evil 
effects  upon  the  artery  that  we  can  diagnosticate  its  existence  during 
life.     These  effects  are  calcification  and  aneurysm. 

Following  the  change  in  the  inner  coat  is  an  inflammation  in  the 
middle  coat,  and  a  deposit  of  calcareous  matter,  carbonate  of  lime,  and 
phosphates.  This  gives  the  vessel  a  firm,  hard  feeling  which  has  been 
compared  to  a  pipestem.  Such  a  condition  affects  the  circulation,  the 
vessel  losing  its  elasticity,  the  flow  of  blood  is  impeded,  the  roughened 
internal  surface  increases  friction,  and,  as  a  consequence,  thrombosis 
and  embolism  are  liable  to  occur.  If  the  supply  of  blood  is  cut  off  in  a 
marked  degree,  we  have  senile  gangrene  as  a  result.  The  arteries  are 
also  liable  to  become  elongated  and  tortuous,  as  is  often  seen  in  the 
temporals  of  aged  people. 

What  we  have  to  look  for  then  is  a  hard,  pipestem-like  condition  in 
the  arteries.  The  vessels  may  also  be  tortuous  and  elongated.  The 
subjects  are  old  people,  men  much  more  frequently  than  women. 

IV.  ANEURYSM. 

An  aneurysm  is  a  tumor  containing  either  fluid  or  coagulated  blood 
and  communicating  with  the  cavity  of  an  artery. 

Aneurysms  are  classified  as  follows  : 

According  to  their  causation  they  are  spoken  of  as  trainnatic  and 
idiopathic.      A  traumatic   aneurysm   is  one  in   which   the  coats  of  a 


Fig.  3. — Sacculated  aneurysm  (Keen  and  White). 

healthy  artery  give  way  under  a  sudden  injury,  forming  a  tumor,  the 
sac  of  which  is  composed  of  the  vessel-wall,  the  cicatrix,  or  a  clot  of 
blood  which  closed  the  wound.  Idiopathic  aneurysms  are  those  which 
are  produced  by  disease  in  the  walls  of  the  vessels.     The  sac  is  com- 


EXAMINATION   OF   THE    VASCULAR   SYSTEM. 


31 


posed  of  one  or  more  of  its  arterial  coats.  When  the  shape  is  taken 
as  the  basis  of  classification  two  varieties  are  recognized :  sacculated 
when  the  wall  at  one  side  of  the  arter>'  is  expanded  into  a  pouch 
(Fig.  3),  and  fusiform  when  the  coats  are  uniformly  dilated  in  the 
whole  circumference  of  the  vessel  and  for  a  considerable  distance  in  its 
length  (Fig.  4).     A  dissecting  aneurysm  (Fig.   5)  is  a  variety  by  itself 


Fig.  4. — Tubulated  or  fusiform  aneurysm  (Keen  and  White). 


Fig.  5. — Plan  of  a  dissecting  aneurysm  (Holmes). 


It  usually  begins  in  the  breaking  down  of  an  atheromatous  ulcer.  The 
blood  makes  its  way  between  the  arterial  coats,  stripping  them  asunder 
and  forming  a  sort  of  fistula  in  the  v^essel-wall.  After  traversing  the 
wall  for  some  distance  the  stream  finds  its  way  back  into  the  vessel  or 
perforates  all  of  the  coats,  and  is  extravasated  into  the  surrounding 
tissues. 

The  terms  true  and  false  aneur}^sm  are  of  little  practical  value.  A 
true  aneurysm  is  one  in  which  all  the  coats  of  the  artery  enter  into  the 
formation  of  the  sac.  This  is  only  possible  when  the  aneurysm  is  of 
small  size.  A  false  aneurysm  has  the  inner  coat  of  the  arten,^  much 
altered  and  thickened,  the  middle  and  outer  coats  have  disappeared, 
and  the  wall  of  the  sac  is  formed  by  the  thickened  connective  tissue  of 
the  surrounding  parts. 

In  examining  for  an  aneur\'sm  our  attention  should  be  directed  to 


32 


SCJ^GICAL   DIAGNOSIS  AXD    TREATMENT. 


the  vessels  upon  w  hich  tlic  greatest  strain  is  thrown.  The  larger  ves- 
sels, too,  are  those  generally  affected.  The  arch  of  the  aorta,  the  part 
where  the  external  iliac  becomes  the  femoral,  the  parts  of  the  arteries 
from  which  branches  arise,  and  the  convexities  of  all  the  curves  are  the 
most  common  seats  of  aneurj-sm. 

The  arteries  of  the  brain  and  those  of  the  lower  limbs,  particularly 
the  popliteal  and  the  splenic,  suffer  frequently. 

Symptoms. — Attention  is  usually  directed  to  an  aneur>'sm  by  the 
pain  which  the  patient  feels.  It  is  generally  severe,  and  may  be 
described  as  sharp  and  lancinating  (in  that  respect  resembling  carci- 
noma), or  it  may  be  aching  or  burning  like  the  pain  of  ulceration.  As 
the  pain  is  due  to  pressure,  the  tumor  is  generally  of  considerable  size 
before  this  becomes  a  marked  symptom.  At  times  a  nerve — the  pop- 
liteal, for  instance — is  flattened  and  stretched  over  the  tumor.    The  pain 


Fig.  6. — Aneurysm  of  the  mammary  artery  (Jepson). 

in  such  a  case  is  intense,  and  is  felt  along  the  course  of  the  nerve.  If 
aneur>'sm  is  located  on  one  of  the  limbs  or  in  a  superficial  position,  we 
expect  to  find  a  tumor  (Fig.  6).  The  following  questions  must  then  be 
answered : 

(a)  Does  the  tumor  pulsate  ?  In  the  first  stage  of  an  aneurysm 
(that  is,  while  the  contents  are  fluid)  distinct  pulsation  can  be  felt.  The 
pulsation  is  peculiar ;  it  is  eccentric,  expansile,  and  synchronous  with  the 
heart-beat.  Place  a  hand  on  each  side  of  the  tumor,  and  with  each 
pulsation  the  palms  will  be  separated  from  each  other.  An  abscess 
may  have  the  fluid  character  of  an  aneurysm,  and,  if  it  happen  to  lie 
over  the  situation  of  an  artery,  a  pulsation  will  be  communicated  to  it. 
In  this  case  the  pulsation  will  be  up  and  down,  and  not  laterally. 


EXAMINATION  OF   THE    VASCULAR  SYSTEM.  33 

{b)  Has  it  a  bruit  ?  In  an  aneurysm,  owing  to  the  roughening  of 
the  lining  of  the  sac  and  to  the  circumstance  of  the  blood  rushing  into 
the  cavity  and  out  again,  a  peculiar  sound  can  be  heard,  not  only  ov^er 
the  tumor,  but  also  along  the  artery  above  and  below  the  sac  for  a 
greater  or  less  distance.  Sometimes  this  sound  is  blowing  in  character, 
or  it  may  be  rasping  like  the  noise  made  by  a  saw.  There  are  malig- 
nant vascular  tumors  which  have  bruits  that  might  be  mistaken  for 
aneurysm,  but  it  must  be  borne  in  mind  that  the  bruit  of  an  aneurysm 
is  heard  along  the  course  of  the  artery  as  well,  while  in  the  case  of 
malignant  tumor  the  sound  is  confined  to  the  growth  itself 

{c)  Can  the  size  of  the  tumor  be  changed  by  pressure  upon  the 
artery  ?  If  we  can  make  pressure  upon  the  artery  on  the  side  of  an 
aneurysm  nearest  the  heart,  we  find  that  the  size  of  the  tumor  is  dimin- 
ished, for  we  cut  off  the  supply-pipe  which  fills  the  cavity.  If,  on  the 
other  hand,  we  press  upon  the  artery  on  the  side  farthest  from  the 
heart,  the  tumor  is  increased,  because  we  obstruct  the  overflow-pipe 
and  increase  the  tension  in  the  sac. 

If  aneurysms  were  always  filled  with  fluid  blood,  the  diagnosis 
would  be  comparatively  easy.  It  is  only  in  their  first  stage  that  such 
is  the  case.  As  the  disease  progresses  there  is  always  a  tendency  to 
the  formation  of  fibrinous  layers,  which  by  degrees  change  the  charac- 
ter of  the  tumor  from  a  fluid  to  a  more  or  less  solid  mass.  This  is 
sometimes  called  the  second  stage.  The  effect  of  this  solidity  is  natu- 
rally to  render  the  pulsation  less  distinct,  so  that  in  some  cases  it  is 
entirely  lost.  It  may  happen  that  the  fibrin  is  not  deposited  evenly  in 
the  sac ;  in  that  case  we  may  find  pulsation  in  certain  portions  of  the 
tumor,  but  not  in  others.  The  tumor  being  solid,  it  will  not  be  changed 
in  size  by  pressure  above  or  below  as  in  the  case  of  an  aneurysm  in  its 
first  stage.  Still,  as  a  rule,  we  have  the  bruit  to  rely  upon,  for  it  can  be 
heard  not  only  over  the  sac,  but  above  and  below  it  along  the  course 
of  the  artery. 

(^)  Are  there  any  pressure-effects  ?  If  the  veins  suffer  from  pres- 
sure, we  will  find  edema  of  the  limb  below  the  tumor.  This,  if  long 
continued,  may  terminate  in  ulceration  or  even  gangrene.  The  effect 
of  constant  pressure  is  to  produce  atrophy ;  hence  we  have  absorp- 
tion of  osseous  tissue  when  bone  is  pressed  upon,  as,  for  instance,  the 
sternum  in  thoracic  aneurysms.  Pressure  upon  the  trachea  produces 
difficulty  of  breathing,  and  almost  a  pathognomonic  sign  of  aneurysm 
of  the  arch  of  the  aorta  is  a  peculiar,  brassy,  unfinished  cough,  due  to 
pressure  upon  the  recurrent  laryngeal  nerve  of  the  left  side.  If 
the  esophagus  suffers  pressure,  difficulty  of  swallowing  will  result. 
Hiccough  is  produced  by  pressure  upon  the  phrenic  nerve,  and  when 
the  sympathetic  nerve  is  pressed  upon  we  see  capillary  congestion. 
Pressure  upon  the  thoracic  duct  prevents  the  chyle  from  entering  the 
blood  and  may  lead  to  death  by  starvation. 

When,  in  spite  of  all  these  inquiries,  you  are  in  doubt,  an  explora- 
tion with  an  aseptic  hypodermic  needle  may  settle  the  point. 

Mistakes  to  be  Guarded  Against. — Pulsating  tumors  which  resemble 
aneurysm  are  most  likely  to  lead  us  to  a  false  diagnosis.  These  are 
the  pulsating  encephaloid,  soft  sarcoma,  erectile  tumors,  and  pulsating 
tumors  of  bone.     The  history  of  the  case,  the  existence  of  arterial 


34 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


degeneration  in  other  parts  of  the  body,  and  the  characters  already- 
described  will,  however,  as  a  rule,  keep  us  from  falling  into  error. 

Treatment  of  Aneurysm. — Nature  in  many  cases  attempts  the  cure 
of  aneurysm,  but  seldom  succeeds.  The  process  of  cure  consists  in  a 
filling  of  the  aneurysmal  sac  by  the  deposit  of  successive  layers  of  fibrin. 
Our  aim  in  treatment  must  be  to  imitate  Nature.  If  we  can  cause  the 
circulation  in  the  sac  to  become  slower,  either  by  occlusion  of  the 
afferent  or  efferent  vessel  or  by  obliteration  of  the  sac  itself,  the  object 
will  be  accomplished.  Medical  and  surgical  measures  are  at  our  dis- 
posal. Of  the  medical  methods,  Tufnell's  is  probably  the  best.  It 
consists  in  confining  the  patient  to  bed  in  the  recumbent  position  for 
several  months  on  restricted  diet,  with  the  view  of  reducing  the  watery 
elements  of  the  blood  and  increasing  its  solid  constituents.  The  diet 
is  restricted  to  ten  ounces  of  solid  and  six  ounces  of  fluid  nutriment 
in  each  twenty-four  hours.  Opium  is  given  to  relieve  pain,  lactucarium 
to  produce  sleep,  and  compound  julap  powder  to  produce  watery  dis- 
charges from  the  bowels. 

Surgieal  Methods. —  i.  Compression. — This  is  a  very  old  method, 
having  been  used  at  least  200  years  ago  ;  its  early  employment,  however, 
was  confined  to  traumatic  aneurysm.  John  Hunter  in  1785  tied  the 
femoral  artery  in  Hunter's  canal  and  established  a  new  principle — viz. 


Fig.  7. — Compression  of  the  femoral  artery  for  popliteal  aneurysm  (after  Esmarch). 

that  it  is  necessary  only  partially,  and  not  completely,  to  intercept  the 
current  through  the  aneurysmal  sac.  This  is  the  aim  of  compression, 
and  it  can  be  carried  out  at  some  distance  from  the  seat  of  the  disease, 
as,  for  instance,  over  the  common  femoral  when  the  popliteal  is  the  seat 
of  aneurysm.  Compression  can  be  applied  by  the  fingers  (relays  of 
assistants  keeping  up  the  treatment  until  the  end  is  attained)  or  by 
compressing  instruments  (Fig.  7)  or  by  flexion  of  the  joints. 

2,  Rapid  cure  by  tourniquet  or  by  Esmarch's  bandage. 

3.  Ligation. — (c?)  Hunter's  method :  The  ligature  is  applied  on  the 
cardiac  side  of  the  tumor,  one  or  more  branches  intervening  between 
the    ligature   jmd   the    sac.     {li)   Anel's    method:    The    same    as    the 


EXAMINATION  OF  THE    VASCULAR  SYSTEM.  35 

preceding,  without  a  branch  between  the  Hgature  and  the  sac.  {c) 
Brasdor's  :  Ligature  on  the  distal  side,  without  an  intervening  branch. 
(d)  Wardrop's  :  The  same  as  the  preceding,  with  an  intervening  branch. 
\e)  The  old  operation  of  Antyllus,  in  which  the  artery  was  tied,  both 
below  and  above  the  sac,  close  to  the  tumor.  This  method  is  now 
adopted  in  cases  of  traumatic  aneurysm  only. 

Other  methods  of  treatment  are  galvano-puncture,  the  use  of 
coagulating  injections,  and  the  introduction  of  foreign  bodies,  such  as 
fine  wire,  into  the  sac. 


V.   SPECIAL   ANEURYSMS. 

Aneurysm  of  the  Arch  of  the  Aorta. — We  cannot  here  follow 
the  line  of  investigation  laid  down  for  superficial  aneurysms.  Pressure- 
symptoms  play  the  most  prominent  part,  and  the  structures  pressed 
upon  will  depend  upon  the  position  of  the  aneurysm  and  upon  its  size. 
At  the  transverse  portion  of  the  arch  there  is  less  room  for  expansion 
than  at  the  other  divisions  of  the  vessel,  owing  to  the  shallowness  of 
the  chest  at  this  part.  Consequently,  the  symptoms  of  pressure  are 
most  marked,  and  make  their  appearance  earlier,  in  this  form  of  the 
disease.  In  aneurysms  of  the  ascending  and  descending  portions  the 
tumor  has  more  room,  and  hence  the  symptoms  of  pressure  are  longer 
delayed. 

{a)  Pain. — From  first  to  last  pain  is  likely  to  prove  the  most  promi- 
nent symptom.  Some  patients  will  describe  a  sudden  tearing  pain  as 
of  something  "  giving  way  "  when  in  a  violent  effort  the  middle  coat  of 
the  vessel  is  ruptured,  and  thus  forms  the  starting-point  of  the  aneurysm. 
Later,  the  pain  is  due  to  the  stretching  of  fine  nerve-filaments  in  the  arte- 
rial coats  or  to  pressure  upon  neighboring  structures.  Anything  which 
increases  blood-pressure  in  the  sac  will  aggravate  the  pain,  and  under 
such  conditions  the  suffering  may  be  excruciating.  When  the  tumor 
presses  against  the  sternum  in  front  or  upon  the  spinal  column  behind, 
a  constant  boring,  dull  pain  is  experienced,  and  erosion  of  the  bones 
results.  In  a  small  proportion  of  cases  great  pressure  may  be  exerted, 
and  yet  the  patient  may  never  complain  of  pain. 

(/;)  Bruit. — The  characteristic  bruit  of  aortic  aneur>^sm  is  a  soft, 
systolic  murmur  heard  over  the  tumor  and  sometimes  along  both 
carotid  arteries. 

(r)  Pressure-symptoms. — When  the  transverse  or  descending  portion 
is  the  seat  of  aneurysm,  the  recurrent  laryngeal  nerve  of  the  left  side, 
which  here  winds  around  the  arteiy,  suffers  from  pressure.  This  pro- 
duces its  effect  upon  the  laryngeal  muscles,  and  the  patient  suffers 
from  a  peculiar  cough.  The  character  of  this  cough  is,  that  it  does 
•not  afford  any  relief  It  has  been  aptly  described  as  an  "  unfinished 
cough." 

Hemoptysis  is  a  result  of  aortic  aneurysm  under  the  following 
conditions:  (i)  The  tumor  may  press  upon  the  trachea,  causing  con- 
gestion and  rupture  of  the  vessels  which  traverse  its  mucous  membrane. 
(2)  The  aneurysm  may  press  upon  the  lung-tissue,  cutting  off  the 
blood-supply  to  a  portion  of  the  pulmonary  substance  and  causing  it  to 
break    down.     (3)  The    aneurysm  may  rupture    into  the    trachea    or 


36  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

bronchial  tubes.  The  amount  and  character  of  the  expectorated  blood 
will  afford  pretty  fair  e\'idence  of  its  source.  If  it  comes  from  the 
trachea,  it  appears  as  a  simple  stainin<^  of  the  mucus  and  the  quantity 
of  blood  is  never  large.  Coming  from  a  portion  of  broken-down  lung, 
it  has  the  character  of  phthisical  hemorrhage.  When  the  aneurysm 
ruptures  into  the  trachea  or  bronchi,  the  first  appearance  of  blood  may 
be  trifling  in  amount;  but  after  the  lapse  of  a  few  hours,  when  the 
rupture  has  had  time  to  enlarge,  blood  may  be  forced  up  in  such 
quantities  as  to  end  the  patient's  life  in  a  few  seconds.  This  is  the 
"  bursting  of  a  blood-vessel  "  which  noxelists  love  to  describe. 

Aneurysm  of  the  Ascending  Portion  of  the  Arch. — The 
.symptoms  peculiar  to  this  aneurysm  are — 

{a)  The  presence  of  a  tumor  which  can  be  felt  to  pulsate  to  the 
right  of  the  sternum  in  the  second  or  third  intercostal  space.  In 
exceptional  cases  the  tumor  may  be  found  to  the  left  of  the  sternum. 
At  first  it  is  obscure,  but  later,  when  by  erosion  the  sternum  becomes 
thinned  or  even  perforated  by  constant  pressure,  the  thrill  and  pul- 
sation may  be  distinctly  felt. 

Aneurysm  of  this  portion  of  the  aorta  is  especially  dangerous, 
owing  to  the  anatomical  fact  that  it  is  covered  only  by  the  thin  serous 
layer  of  the  pericardium  which  allows  of  the  coats  becoming  rapidly 
distended  and  favors  rupture  into  the  pericardial  sac. 

In  examining  the  tumor  remove  all  clothmg  from  the  chest  and 
place  the  patient  in  a  strong  light.  Slight  pulsations  are  best  observed 
by  viewing  the  chest  transversely  from  the  side,  the  examiner's  eye 
being  brought  almost  on  a  line  with  the  front  of  the  chest.  Aneurysmal 
pulsation  is  expansile,  not  only  rising  and  falling,  but  expanding  later- 
ally with  the  heart-beats.  To  demonstrate  this  lateral  expansion  the 
following  simple  expedients  may  be  resorted  to :  {li)  Cover  the  promi- 
nence with  a  piece  of  adhesive  plaster  which  has  a  slit  cut  down  its 
middle  line.  If  the  pulsation  be  expansile,  the  slit  will  be  seen  to 
widen  with  each  pulsation  (Fagge  and  Pye  Smith).  {8)  Fix  light 
paper  columns  or  cones  of  cotton-wool  to  opposite  points  of  the 
tumor :  if  these  cones  be  found  to  diverge  with  each  pulsation,  the 
tumor  is  expansile ;  or  two  single  stethoscopes  can  be  used  in  a  sim- 
ilar manner. 

By  palpation  a  pulsation  or  thrill  may  be  felt.  If  this  is  observed  in 
the  upper  part  of  the  sternum,  it  may  be  set  down  as  an  aneurysm  of 
the  ascending  or  transverse  portion  of  the  arch. 

[b)  By  auscultation  a  murmur  may  be  heard  over  the  aorta  or  aneur- 
ysmal tumor,  but  in  some  cases  this  murmur  is  absent.  In  such  cases 
Sanson!  recommends  that  the  patient  place  within  his  mouth  the  small 
chest-piece  of  the  binaural  stethoscope  and  close  his  lips  over  it.  In 
this  way  a  distinct  or  loud  systolic  murmur  may  be  heard  in  the  case 
of  a  thoracic  aneurysm,  the  "  vibrations  being  communicated  to  the 
trachea  and  thence  directly  by  the  air-column  to  the  ears." 

Pain  is  usually  present,  and  there  is  tenderness  on  pressure  over  the 
seat  of  the  aneurysm. 

(r)  The  pressure-symptoms  are  manifested  according  to  the  growth 
of  the  tumor  and  its  encroachments  upon  the  neighboring  structures. 
As  it  grows  toward  the  right,  the  vena  cava  superior  is  the  first  to 


EXAMINATIOX   OF   THE    VASCULAR   SYSTEM.  37 

suffer  pressure,  and  as  a  result  there  are  v^enous  engorgement  and 
edema  of  the  upper  hmbs. 

Toward  the  left  it  presses  upon  the  pulmonary  artery,  and  produces 
dilatation  in  the  right  side  of  the  heart  and  pulmonary  symptoms 
resembling  phthisis.  As  the  tumor  grows  upward  it  presses  upon  the 
upper  lobe  of  the  right  lung  or  its  bronchus.  As  evidence  of  this  the 
breathing  becomes  impaired,  and  later,  when  the  air  is  shut  out  of  the 
lung,  there  is  a  dull  area  on  percussion.  If  the  recurrent  laryngeal 
nerve  be  compressed,  there  will  be  the  peculiar  unfinished  cough 
of  aortic  aneurysm. 

It  is  not  uncommon  in  large  aneurysms  to  find  the  heart  displaced 
to  the  left  and  downward.  Pressure  upon  the  inferior  vena  cava  is  a 
very  rare  symptom.  It  is  manifested  by  edema  of  the  lower  limbs  and 
ascites. 

Aneurysm  of  the  Transverse  Portion  of  the  Arch. — As  this 
portion  of  the  vessel  lies  behind  the  trachea,  a  tumor  connected  with  it 
is  almost  sure  to  interfere  with  respiration.  Hence  its  most  frequent 
manifestations  are  a  suffocative  cough,  severe  dyspnea,  and  stridulous 
breathing.  Sometimes  the  pressure  is  exerted  upon  the  left  bronchus, 
interfering  with  the  expansion  of  the  left  lung  and  causing  a  deficient 
respiratory  murmur.  The  esophagus  may  be  pressed  upon,  causing 
difficulty  in  swallowing  and  symptoms  of  stricture.  Pressure  on  the 
left  recurrent  laryngeal  nerve  causes  paralysis  of  the  left  vocal  cord. 
Sometimes  the  pupils  are  unequally  dilated,  the  pupil  of  the  affected 
side  being  contracted.  This  is  due  to  pressure  on  the  branches  of  the 
sympathetic  nerve. 

Tracheal  tugging  is  an  important  sign  of  aneurysm  in  this  locality. 
The  simplest  way  of  observing  this  sign  is  that  of  Ewart.  The  ex- 
aminer stands  behind  the  patient,  who  is  seated  in  a  chair  with  his 
head  slightly  thrown  back  and  steadied  against  the  examiner's  chest. 
The  tips  of  the  index  fingers  are  placed  beneath  the  cricoid  cartilage, 
which  is  gently  raised  by  them.  With  each  beat  of  the  heart  a  tugging 
sensation  is  experienced  by  the  fingers.  Surgeon-Major  Oliver's 
method  is  as  follows :  The  patient  is  placed  in  the  erect  position, 
directed  to  close  his  mouth  and  raise  the  chin  to  the  fullest  extent. 
The  cricoid  cartilage  is  then  grasped  between  the  finger  and  thumb  and 
gently  pressed  upward.     When  a  tugging  is  felt  an  aneurysm  is  present. 

In  all  cases  of  suspected  aneurysm  the  voice  should  be  carefully 
studied.  A  shrill  or  crowing  voice  or  one  lowered  to  a  whisper  or 
assuming  a  falsetto  character  should  attract  attention.  A  loud,  brassy 
cough,  which  has  been  so  well  described  as  the  unfinished  cough  of 
aneurysm,  is  especially  significant,  and  is  due  to  pressure  upon  the  left 
recurrent  laryngeal  nerve.  A  laryngoscopic  examination  should  never 
be  omitted,  for  the  vocal  cords  frequently  give  evidence  of  pressure 
when  there  are  no  other  respiratory  symptoms. 

The  evidence  gained  by  the  laryngoscope  is  thus  summarized  by 
Sansom :  "  On  examination  the  observer  may  see  that  in  ordinary 
inspiration  there  is  little  if  any  difference  in  the  position  of  the  two 
vocal  cords ;  the  left  may  be  a  little  nearer  the  median  line.  The  left 
capitulum  Santorini  and  the  left  aryteno-epiglottidean  fold  may  be  on 
a  somewhat  higher  level  than  their  fellows  on  the  opposite  side.     On 


38  ■     SURGICAL    DIAGNOSIS  AND    TREATMENT. 

phonation,  the  patient  being  asked  to  make  the  sounds  softly  of  "  ah  " 
and  "  ay,"  the  left  vocal  cord  may  be  seen  to  remain  fixed,  while  the 
right  advances  to  the  median  line,  or  the  right  vocal  cord  may  be  seen 
to  advance  to  the  middle  line  and  project  beyond  it.  It  may  encroach 
so  far  as  to  meet  the  flaccid  left  cord,  the  cartilages  overlapping  when  a 
high  note  is  sounded.  Thus,  while  the  whole  of  the  right  cord  is  in 
view,  only  a  portion,  about  half  or  one-third,  of  the  left  cord  can  be 
seen." 

The  size  of  the  pupils  should  be  carefully  studied  in  the  diagnosis 
of  thoracic  aneurysm.  In  common  with  other  intrathoracic  growths, 
aneurysms  may  cause  destruction  of  .sympathetic  nerve-elements  by 
their  pressure.  Destruction  of  nerve-elements  in  the  aneurysmal  sac 
is  followed  by  paralysis  of  the  cilio-spinal  branches  of  the  sympathetic ; 
there  is  a  paralysis  of  the  dilator  muscle  of  the  iris  supplied  by  the 
sympathetic,  and  consequently  an  unopposed  action  of  the  sphincter  of 
the  pupil  supplied  by  the  third  nerve  (Sansom).  The  left  pupil  is  the 
one  usually  contracted,  and  this  should  be  regarded  as  a  strong  con- 
firmatory sign  of  aneurysm.  Examination  of  the  arteries  of  the  upper 
extremities  and  neck  sometimes  affords  valuable  evidence.  The  ascend- 
ing portion  of  the  aortic  arch  gives  off  no  branches ;  the  transverse 
portion  gives  off  the  innominate,  the  left  carotid,  and  the  left  subclavian. 
If  the  aneurysm  be  confined  to  the  first  portion,  the  pulse-wave  in  the 
carotids,  brachials,  etc.  will  be  unchanged.  But  let  the  innominate 
become  involved,  and  the  arteries  on  the  right  side  will  show  a  dimin- 
ished pulse-wave,  while  those  on  the  left  remain  normal.  In  palpating 
the  arteries  begin  with  those  nearest  the  aorta — viz.  the  carotids  ;  then 
the  brachials ;  and  lastly  the  radials.  The  points  to  look  for  are 
enfeeblement  of  the  pulse-wave  in  the  large  arteries  and  delay  in  the 
radial  pulse.  Aneurysm  of  the  transverse  portion  of  the  arcJi  involving 
the  innoniinate,  or  an  aneurysm  of  the  innominate  itself,  produces  a  feeble 
pulse-wave  in  the  arteries  of  the  right  side  and  a  delayed  or  obliterated 
right  radial  pulse. 

Aneurysm  of  the  Descending  Portion  of  the  Arch. — This 
portion  of  the  aorta  lies  near  the  spinal  column,  and  consequently  its 
pressure-symptoms  are  associated  with  this  bony  structure.  Pain  is 
felt  near  the  spine  in  one  or  both  interscapular  regions,  and  it  may  run 
round  the  chest-wall  in  the  form  of  intercostal  neuralgia.  The  pain  is 
described  as  aching  or  boring,  like  all  pain  due  to  erosion  of  bone. 
When  the  destruction  of  osseous  tissue  has  advanced  far  enough  to 
allow  of  pressure  on  the  spinal  cord  paralytic  symptoms  speedily 
develop.  Other  pressure-symptoms  are — {a)  upon  the  esophagus, 
causing  dysphagia  or  even  stricture ;  {li)  upon  the  left  bronchus, 
causing  enfeebled  respiratory  murmur  on  that  side,  sometimes  bron- 
chitis, pneumonia,  or  symptoms  resembling  phthisis.  The  aneurysm 
may  rupture  into  the  esophagus,  but  more  frequently  into  the  pleura. 

It  is  difficult  to  differentiate  between  aneurysm  of  the  arch  of  the 
aorta  and  a  similar  condition  of  the  innominate,  left  subclavian,  and  left 
carotid.  The  following  points,  as  given  by  Wyeth,  will  aid  in  arriving 
at  a  diagnosis  :  The  tumor  in  aneurysm  of  the  ascending  arch  is  usually 
first  noticed  to  the  right  of  the  sternum,  between  the  clavicle  and  the 
third  rib.     The  pressure-symptoms  do  not  affect   the  voice  until  the 


EXAMINATION  OF  THE    VASCULAR   SYSTEM.  39 

tumor  is  recognizable  in  the  right  side  of  the  root  of  the  neck,  where  it 
involves  the  right  recurrent  laryngeal  nerve.  Respiration  may  be  inter- 
fered with  or  cough  produced  by  compression  of  the  right  bronchus. 
This  condition  will  be  recognized  by  the  hissing  rales  distributed  over 
the  area  of  the  right  lung.  Aneurysm  of  the  transverse  arch  is  usually 
first  recognized  to  the  left  of  the  sternum  at  about  the  same  plane  as 
for  the  ascending  segment.  Laryngoscopical  examination  will  demon- 
strate that  whatever  of  muscular  paresis  exists  is  confined  to  the  left 
vocal  bands.  If  the  tumor  rises  into  the  neck,  its  appearance  will  have 
been  preceded  by  pressure-symptoms  of  longer  duration  and  greater 
severity  than  in  either  innominate,  carotid,  or  subclavian  aneurysm. 

Innominate  aneurysm  usually  appears  at  the  upper  margin  of 
the  sternum  in  the  space  between  the  two  tendons  of  origin  of  the  right 
sterno-mastoid  muscle  or  in  the  interclavicular  notch.  The  disturbance 
of  the  circulation  through  this  vessel  so  affected  may  be  recognized  by 
the  difference  in  the  force  and  character  of  the  pulse-wave  in  the  radial 
arteries  of  the  two  arms.  In  aortic  aneurysm,  when  the  innominate  is 
not  compressed  by  the  tumor,  the  pulse-wave  is  the  same  in  both  arms. 
It  must,  however,  be  borne  in  mind  that  in  sacculated  aneurysms, 
springing,  as  they  not  infrequently  do,  from  the  arch  in  immediate 
proximity  to  the  orifice  of  the  innominate,  and  rising  to  the  root  of  the 
neck  in  front  of,  or  behind  this  artery,  a  positiv'C  diagnosis  is  scarcely 
possible.  The  pressure  on  the  innominate  may  retard  or  weaken  the 
right  radial  pulse. 

Aneur)^sm  of  the  left  carotid  artery  first  appears  at  the  left  sterno- 
clavicular articulation  in  the  line  of  this  vessel.  The  murmur  is  trans- 
mitted toward  the  distribution  of  the  carotid,  and  is  not  heard  in  its 
fellow  opposite. 

When  the  left  subclavian  is  involved,  the  swelling  usually  appears  to 
the  left  of  the  sterno-mastoid  muscle,  and  the  pulse  in  the  left  radial 
differs  from  that  of  the  right. 

Treatment  of  Aortic  Aneurysm. — The  treatment  of  aortic 
aneur^'sm  may  be  considered  under  the  following  heads  : 

Rest  is  the  first  consideration,  and  should  be  resorted  to  at  the 
earliest  possible  period.  It  lessens  the  tendency  to  rupture  of  the 
aneur>^sm,  and  it  helps  to  arrest  the  growth  of  the  sac  by  diminishing 
the  blood-pressure.  A  person  in  health  having  a  pulse-rate  of  70 
while  in  the  sitting  posture  will  have  a  pulse  of  78  when  standing. 
The  difference  between  the  recumbent  and  erect  posture  in  a  person 
suffering  from  aortic  disease  is  still  greater ;  hence  a  saving  of  many 
pulsations  may  be  effected  in  the  twenty-four  hours  by  keeping  the 
patient  at  rest. 

Diet. — Tufnell's  method  of  feeding  is  the  best  yet  adopted.  It  con- 
sists in  giving  ten  ounces  of  solids  and  eight  ounces  of  liquids  in  each 
twenty-four  hours.  The  diet  list  for  such  a  patient  is  as  follows : 
breakfast,  two  ounces  of  white  bread  and  butter  and  two  ounces  of 
milk  or  cream ;  dinner,  three  ounces  of  meat  and  three  ounces  of 
potatoes  or  bread,  and  four  ounces  of  water  or  claret ;  supper,  two 
ounces  of  bread  and  butter  and  two  ounces  of  milk  or  tea. 

Mcdicijie. — lodid  of  potassium  has  proved  itself  the  best  drug,  and 
was    first    advocated   by   Balfour    in   Great    Britain   and    Bouillaud   in 


40  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

r^rancc.  To  commence  the  treatment,  five  grains  should  be  taken 
three  times  a  day ;  at  the  end  of  a  week  this  should  be  increased  to  ten 
grains,  and  later  to  fifteen  or  twenty  grains  thrice  a  day.  These  doses 
can  be  keep  up  for  weeks,  months,  or  even  years.  When  there  is 
excessive  heart-action  or  palpitation,  aconite  in  one-  or  two-minim  doses 
given  every  hour  affords  great  relief  Pain  is  controlled  by  hypodermic 
injections  of  morphine. 

Anesthesia  is  recommended  by  Sansom,  not  only  as  indispensable 
during  the  operative  procedures  about  to  be  described,  but  as  a  valuable 
therapeutic  measure  previous  to,  and  perhaps  in  substitution  of,  surgical 
interference.  The  cases  most  suitable  for  treatment  by  anesthesia  are 
those  in  which  there  is  severe  pain,  either  continuous  or  paroxysmal. 
Chloroform  is  given  daily  for  several  days,  and  the  patient  is  kept  under 
its  influence  for  several  hours  each  time.  The  effect  of  prolonged 
anesthesia  is  to  allow  time  for  coagulation  of  the  blood  within  the  sac. 

Operative  Measures. — Distal  ligature  is  attended  with  a  fair  degree 
of  success.  When  the  transverse  portion  of  the  arch  or  the  innominate 
or  the  portion  of  the  aorta  close  to  the  innominata  is  the  seat  of  aneur- 
ysm, the  right  carotid  should  be  tied  or  the  right  carotid  and  right 
subclavian.  Ligation  of  the  left  carotid  has  also  been  practised,  and 
with  good  results  in  several  cases.  The  operation  is  less  dangerous 
than  the  tying  of  both  vessels  on  the  right  side,  collateral  circulation 
being  carried  on  more  easily. 

Galvano-puncture  is  attended  with  considerable  danger,  but,  as  the 
cases  for  which  it  is  demanded  are  otherwise  hopeless,  the  patient  may 
justly  claim  the  chance  which  it  holds  out.  Of  114  cases  in  which  it 
has  been  employed,  68  were  improved  (Petit,  cited  by  Sansom).  It  is 
employed  as  follows  :  Having  taken  all  the  precautions  required  for 
making  the  operation  antiseptic,  two  needles  are  pushed  through  the 
skin  covering  the  tumor  and  into  the  sac.  The  needles  are  then  con- 
nected with  the  poles  of  the  battery  and  a  current  of  from  twent>'  to 
thirty  milliamperes  turned  on.  The  positive  needle  is  then  moved 
about  in  the  sac  so  as  to  touch  the  wall  of  the  aneur>'sm  at  different 
points.  This  is  kept  up  for  ten  to  twenty  minutes,  after  which  the 
current  is  gradually  reduced  and  the  needles  disconnected.  The 
positive  needle  is  first  to  be  withdrawn.  Should  it  be  covered  with 
fibrin  so  as  to  prevent  its  withdrawal,  the  current  must  be  reapplied  in 
the  opposite  direction  until  the  needle  is  loosened.  The  object  of  this 
operation  is  to  cause  coagulation  of  the  contents  of  the  sac. 

The  risks  of  the  operation  are — {a)  The  blood  may  coagulate  in  the 
center  of  the  sac,  the  clot  remaining  soft,  and  finally  breaking  up  in  the 
blood-current,  {b)  Blood  may  spurt  freely  from  the  punctures  made 
by  the  needles,  and  death  may  follow  from  inflammation  of  the  sac. 
{c)  Small  coagula  may  be  carried  off  in  the  circulation. 

Introduetio7i  of  Foreign  Substances  into  the  Sac. — W'ire  has  been 
passed  into  the  sac  through  a  fine  cannula,  and  the  cavity  filled  with 
coils  with  the  object  of  inducing  coagulation.  This  measure  has 
been  so  unsatisfactory  that  it  is  now  practically  abandoned.  Never- 
theless, one  or  two  cases  have  been  cured  in  this  manner.  Macewen 
introduces  metallic  needles  into  the  sac,  leaving  them  in  position  for 
twenty-four  hours,  and  then  withdrawing  them. 


EXAMIXATION   OF  THE    VASCULAR   SYSTEM.  4 1 

Aneurysm  of  the  Carotid. — The  common  carotid  is  liable  to 
aneun'sm  at  any  part  of  its  course,  but  more  particularly  at  its  bifur- 
cation. This  arter}^  departs  from  the  rule  that  aneurysm  is  more  com- 
mon in  men  than  women,  for  in  this  case  the  sexes  suffer  equally. 
Some  authors  speak  of  two  varieties,  the  high  and  the  low,  the  low 
being  confined  almost  entirely  to  the  right  side. 

A  tumor  along  the  course  of  the  common  carotid  with  expansile 
pulsation  and  bruit  is  very  likely  to  be  an  aneurysm.  Further  evidence 
would  be  the  following  pressure-symptoms  :  dyspnea,  spasmodic  cough, 
and  hoarseness  from  pressure  upon  the  trachea,  the  recurrent  laryngeal, 
or  the  larynx ;  difficulty  of  swallowing  from  pressure  upon  the  esoph- 
agus or  upon  the  pharynx  in  the  case  of  the  internal  carotid  ;  neuralgia 
from  pressure  of  the  cervical  nen^es  ;  contraction  of  the  pupils  from 
pressure  upon  the  sympathetic ;  edema  from  pressure  upon  the  internal 
jugular  or,  in  rare  cases,  upon  the  left  subclavian. 

In  most  cases  the  diagnosis  is  very  easy,  but  when  low  down  in  the 
root  of  the  neck  a  positive  opinion  is  difficult  to  arrive  at,  and  in  some 
cases  a  clear  diagnosis  is  impossible.  It  is  impossible  at  times  to  say 
that  aneurysm  of  the  carotid  exists  alone,  for  a  similar  condition  of  the 
subclavian,  the  innominate,  or  the  arch  of  the  aorta  may  strongly  simu- 
late it.  The  rules  for  differentiating  already  given  may  aid  in  coming 
to  a  decision.  Cysts  lying  upon  the  common  carotid  should  not  lead 
any  one  into  error,  for  the  character  of  the  pulsation  is  not  expansile. 
Enlarged  lymphatic  glands  are  not  likely  to  cause  doubt,  for  these 
occur  in  groups  and  are  lobulated.  A  rare  condition  which  might 
give  rise  to  a  disastrous  error  is  aneurysm  of  the  internal  carotid 
pressing  upon  the  tonsil  and  simulating  an  abscess.  Abscess  of  the 
tonsil  is  an  acute  disease,  which,  as  a  rule,  runs  its  entire  course  in 
about  nine  days,  while  aneurysm  is  a  chronic  affection,  and  must  have 
existed  for  many  weeks  before  enlargement  of  the  tonsil  is  produced. 
Besides  this,  tonsillitis  is  attended  with  high  fever  and  other  symptoms 
characteris'tic  of  local  inflammation. 

TrcatJiu'iit. — If  there  is  sufficient  room,  the  vessel  should  be  ligated 
on  the  proximal  side  of  the  aneurysm,  otherwise  on  the  distal  side. 

Vertebral  Aneurysm. — Aneurj^sm  of  the  vertebral  arter)^  is,  as  a 
rule,  of  traumatic  origin.  It  may  be  confounded  with  aneurysm  of  the 
carotid.  The  point  may  readily  be  settled  by  pressing  upon  the  com- 
mon carotid.  If  the  artery  be  pressed  firmly  backward  at  its  bifurcation, 
the  circulation  in  the  sac  will  be  diminished  if  in  a  branch  of  the  carotid, 
but  unaffected  if  the  vertebral  is  the  divte.ry  involved. 

It  cannot  be  too  strongly  impressed  upon  the  examiner  that  rough 
handling  of  an  aneur^^sm  is  to  be  avoided,  owing  to  the  danger  of 
detaching  a  clot  which  might  be  carried  off  in  the  circulation  to  form 
an  embolus.  That  caution  is  particularly  applicable  to  aneurysms  in 
this  locality,  for  a  detached  clot  might  readily  be  carried  to  the  brain 
and  produce  disastrous  consequences. 

Orbital  or  Ophthalmic  Aneurysm. — The  ophthalmic  artei-)^ 
may  be  the  seat  of  aneurysm,  either  in  the  orbital  cavity  or  within 
the  cranium.  Many  of  the  cases  of  orbital  aneurysm  are  not  true 
dilatations  of  the  artery,  but  pulsating  tumors,  angeiomata,  or  arterio- 
venous aneurysms.     The  diagnosis  is  readil)'  settled  b}'  pressure  upon 


42  SURGICAL    DIAGNOSIS  AXD    TREATMENT. 

the  common  carotid.  If  pulsation  ceases,  it  points  to  the  treatment, 
which  is  ligation  of  the  carotid — an  operation  whicii  has  been  attended 
with  about  75  per  cent,  of  cures. 

Subclavian  Aneurysm. — The  artery  is  divided  into  three  parts  : 
the  first  part  on  the  rit^iit  side  ascends  obliquely  outward  from  the  origin 
of  the  vessel  to  the  inner  border  of  the  scalenus  anticus  muscle.  On  the 
left  side  it  ascends  vertically  to  gain  the  inner  border  of  that  muscle 
(Gray).  The  second  part  passes  outward  behind  the  scalenus  anticus. 
The  third  part  passes  from  the  outer  margin  of  that  muscle  beneath 
the  clavicle  to  the  lower  border  of  the  first  rib,  where  it  becomes  the 
axillary. 

Landmarks. — Near  the  outer  border  of  the  sterno-mastoid,  and 
about  one  inch  above  the  clavicle,  the  pulsations  of  the  artery  can  be 
felt.  Behind  it  is  the  first  rib,  against  which  the  vessel  can  be  readily 
compressed.  Stand  behind  the  patient's  shoulder  and  make  compression 
with  the  thumb  in  the  downward  direction  and  a  little  inward. 

The  third  portion  of  the  artery  is  the  part  most  frequently  involved. 
Next  in  order  comes  the  first  part,  while  the  middle  portion,  owing  to 
its  having  the  firm,  resisting  scaleni  muscles  in  front  of  it,  is  least  likely 
to  be  the  seat  of  aneurysm.  The  right  side  is  much  more  frequently 
affected  than  the  left.  Generally  speaking,  the  first  indication  of 
aneurysm  of  the  subclavian  is  a  tumor  felt  behind  the  clavicle  and  to 
the  outer  side  or  behind  the  sterno-mastoid  muscle.  In  its  full  devel- 
opment it  forms  an  elongated  tumor  behind  and  above  the  clavicle,  and 
has  a  tendency  to  rupture  before  attaining  a  large  size. 

Errors  in  diagnosis  are  apt  to  occur — first,  by  mistaking  a  glandular 
or  other  tumor  for  an  aneurysm,  just  as  in  the  case  of  the  carotid. 
The  absence  of  expansile  pulsation  and  the  fluidity  of  the  tumor 
should  remove  all  doubt.  Second,  it  may  be  difficult  to  determine 
from  what  vessel  the  aneurysm  springs.  The  history  will  help  us.  An 
aortic  aneurysm  produces  pressure-symptoms,  and  often  causes  death 
long  before  it  reaches  the  position  of  the  subclavian.  On  the  right  side, 
therefore,  the  question  is  easily  settled.  On  the  left  side  aneurysm  of 
the  subclavian  is  rare,  but  the  diagnosis  is  more  difficult.  Attention  to 
the  following  points  may  be  of  service :  A  tumor  in  the  neck  appears 
early  in  the  case  of  subclavian  aneurysm,  late  in  the  case  of  an  aortic. 
The  return  circulation  in  the  arm  is  interfered  with  in  the  case  of  the 
subclavian ;  not  at  all  or  late  when  the  aorta  is  affected.  The  radial 
pulse  is  changed  in  rhythm  and  volume  on  the  affected  side  in  sub- 
clavian aneurysm,  while  if  the  second  or  third  portion  of  the  arch  of 
the  aorta  is  the  seat,  there  is  no  change  in  the  radial  pulse  until  the 
branches  are  affected. 

Treatment. — Tufnell's  treatment  should  first  be  tried.  Compression 
on  the  proximal  side  of  the  aneurysm  is  only  possible  when  the  third 
portion  is  involved.  Ligation  of  the  artery  is  most  successful  when 
applied  to  the  distal  side.  As  a  last  resort  the  artery  may  be  tied  at 
the  proximal  side  of  the  aneurysm  and  the  arm  amputated  at  the 
shoulder-joint. 

Axillary  Aneurysm. — The  right  side  is  much  more  frequently 
affected  than  the  left,  and  in  most  cases  the  aneurysm  can  be  traced  to 
an  injury.     The  growth  of  the  tumor  is  rapid,  and  may  be  found  pro- 


EXAMINATION   OF   THE    VASCULAR   SYSTEM.  43 

jecting  downward  into  the  axilla,  inward  and  against  the  thorax,  in 
some  cases  causing  absorption  of  the  ribs  from  pressure;  or  upward 
under  the  clavicle,  in  which  case  the  shoulder  is  elevated.  The  move- 
ments of  the  arm  are  interfered  with,  the  head  is  drawn  to  the  same 
side,  and  the  elbow  is  abducted.  The  more  prominent  pressure-symp- 
toms are  pain  running  down  the  arm  from  the  brachial  plexus,  and 
edema  from  interference  with  the  return  circulation  through  the  axillary 
vein. 

Trcatinoit. — Compression,  either  digital  or  instrumental,  to  the  third 
portion  of  the  artery  should  first  be  given  a  thorough  trial.  Failing  in 
this,  the  vessel  should  be  ligated  at  this  point. 

Aneurysm  of  arteries  below  the  axillar}'  are  rare,  and  usually  the 
result  of  injury.  They  present  no  special  difficulty  in  diagnosis,  and 
can  be  recognized  by  the  general  principles  already  laid  down. 

Aneurysm  of  the  Abdominal  Aorta. — Any  part  of  the  artery 
may  be  the  seat  of  aneurysm,  but  the  most  common  position  is  near  the 
diaphragm.  The  whole  arter\'  may  be  expanded  in  the  form  of  a  large 
fusiform  aneurysm,  or  the  tumor  may  be  of  the  dissecting  or  sacculated 
variety.  One  or  other  of  the  branches  of  the  aorta  may  be  involved  or 
even  obliterated  by  pressure. 

History. — There  is  generally  a  history  of  injury  or  severe  muscular 
effort  or  continued  laborious  employment.  If  the  aneurysm  is  idio- 
pathic, the  disease  of  the  vessel  is  likely  to  be  extensive.  In  the  early 
period  the  symptoms  are  obscure. 

Pain  varies  in  character,  sometimes  continuous,  sometimes  parox- 
ysmal— in  some  cases  running  along  the  course  of  the  nerves,  in  others 
confined  to  one  fixed  position.  When  pain  is  continuous,  it  is  due  to 
erosion  of  the  spinal  column,  and  is  characterized  as  gnawing  or  boring, 
referred  to  the  back,  sometimes  at  a  fixed  point  over  one  of  the  verte- 
brje.  This  pain  is  relieved  when  the  patient  assumes  the  recumbent 
position  with  the  face  downward :  it  is  aggravated  by  localized  pressure 
and  by  such  movements  as  stamping  or  riding  in  a  jolting  vehicle.  An 
advanced  stage  of  erosion  may  result  in  paralysis  due  to  involvement 
of  the  spinal  cord. 

Pulsation. — The  pulsation  is  expansile  and  attended  with  a  bruit, 
which  can  be  heard  not  only  in  front,  but  behind.  The  most  distinct 
pulsation  is  found  a  little  to  the  left  of  the  middle  line  and  near  the 
ensiform  cartilage.  This  is  especially  the  case  when  the  aneurysmal  sac 
bulges  forward.  Pulsation,  on  the  other  hand,  may  be  absent  if  the 
sac  points  laterally  and  posteriorly.  If  the  tumor  is  high  up  and 
shielded  by  the  pillars  of  the  diaphragm,  it  may  attain  an  enormous 
size  without  showing  signs  of  pulsation.  In  such  cases  the  diagnosis 
must  rest  upon  the  subjective  symptoms,  especially  pain.  In  rare  cases 
a  heaving  pulsation  is  apparent  near  the  dorsal  and  lumbar  vertebrae 
and  the  adjoining  ribs  and  interco.stal  spaces. 

Prcssnrc-syuiptouis. — Pressure  upward  against  the  diaphragm  pro- 
duces dyspnea ;  against  the  stomach  and  intestines,  dyspepsia,  colic,  or 
other  disorders  of  digestion  ;  against  the  bile-duct,  jaundice.  One  or 
other  of  the  abdominal  organs,  such  as  the  liver  or  kidneys,  may  be 
pushed  aside.  The  tumor  does  not  move  with  the  diaphragrti.  Although 
it  generally  increases  in  size  in  the  direction  of  least  resistance,  a  small 


44 


SCA'G/C.U.    jn.iGXOS/S  AND    TKEAIMEAV. 


proportion  of  cases  press  clirectl)'  upon  the  spinal  column,  producing 
erosion  of  the  bones. 

lirrors  to  l)c  Avoided. —  In  thin  persons  the  abdominal  aorta  is  readily 
felt,  and  a  strong  pulsation,  with  a  slight  amount  of  expansion  at  each 
diastolic  movement,  can  be  readily  mistaken  for  aneurysm.  Abdominal 
pulsation,  according  to  Douglas  Powell,  is  due  to  vasomotor  disturb- 
ance, and  may  be  induced  by  hemic,  emotional,  malarial,  and  reflex 
causes.  The  advice  of  Sir  William  Jenner  is  worth  bearing  in  mind : 
"  Instead  of  being  your  first,  it  should  be  your  last  idea  that  abdom- 
inal pulsation  is  due  to  aneurysm." 

Aneurysm  of  the  Branches  of  the  Abdominal  Aorta. — An>- 
of  the  branches  may  be  the  seat  of  aneurysm,  but  the  vessels  most 
commonly  affected  are  the  celiac  axis  and  the  superior  mesenteric.  In 
our  decision  we  must  be  guided  by  the  general  character  of  aneurysm 


Fig.  8. — Aneurysm  of  the  celiac  axis. 

and  the  position  of  the  tumor.  When  the  celiac  axis  is  the  seat  of  the 
disease  the  tumor  projects  forward  toward  the  right  side  under  the 
liver.  In  the  only  case  of  this  form  of  aneurysm  that  has  come  under 
my  observation  the  tumor  was  on  the  left  side  near  the  middle  line. 
The  post-mortem  revealed  an  aneurysm  of  the  celiac  axis  about  4 
inches  in  diameter  (Fig.  8).  When  the  superior  mesenteric  is  involved 
the  tumor  is  more  movable,  except  when  the  origin  of  the  vessel  is  the 
part  dilated. 

Iliac  Aneurysm. — The  common  iliac  or  the  internal  or  external 
branch   may   be   the   seat  of  aneurysm.     The   tumor  is   soft,  circum- 


EXAMINATION  OF   THE    VASCULAR   SYSTEM. 


45 


scribed,  expansile,  and  the  bruit  can  be  heard  along  the  course  of  the 
artery.  Pain  is  not  severe,  except  when  the  genito-crural  or  obturator 
nerve  is  involved.  Owing  to  the  room  for  expansion,  the  pressure- 
symptoms  are  not  marked  until  the  tumor  has  attained  a  large  size.  In 
a  few  cases  the  veins  have  been  obstructed,  resulting  in  edema  and 
gangrene.  Additional  evidence  can  sometimes  be  gained  by  an  exami- 
nation per  vaginam  or  rectum. 

The  errors  in  diagnosis  to  be  guarded  against  are — i.  Abscess  in 
the  neighborhood  of  Poupart's  ligament.  The  error  is  more  liable  to 
occur  from  the  fact  that  an  aneurysm  may  contain  pouches,  which, 
lying  beneath  the  ligament,  may  fluctuate,  but  do  not  pulsate.    Lancing 


bv  Dr.  Rrown). 


a  supposed  abscess  under  these  circumstances  would  be  a  serious 
blunder.  2.  Pulsating  sarcomata  and  tumors  growing  from  the  bones 
are  difficult  to  distinguish  from  aneurysm.  Our  reliance  must  be  placed 
upon  the  position  of  the  tumor,  its  connection  with  bone,  the  want  of 
the  characteristic  bruit,  and  the  general  characters  already  described. 

Treatmoit. — In  the  common  iliac.  Tufnell's  treatment  should  be 
tried.  If  this  fail,  proximal,  with  or  without  distal,  pressure  may  be 
successful.  In  the  external  iliac  the  same  treatment  should  be  em- 
ployed, failing  which  the  external  or  common  iliac  may  be  ligated. 
Distal  ligature  in  this  locality  has  never  been  successful. 


46  SURGICAL    DIAGNOSIS  AND    IREATMENT. 

Femoral  Aneurysm. — Landmarks. — At  a  point  midway  between 
the  anterior  superior  sj)ine  of  the  ilium  and  the  symphysis  pubis  the 
arter\-  ean  be  feU  pulsatin^^.  From  this  point  to  the  spur-hke  tubercle 
for  the  insertion  of  the  adductor  magnus  on  the  inner  side  of  the  knee 
draw  a  straight  line.  The  femoral  artery  lies  under  the  upper  two- 
thirds  of  this  line.  The  profunda  rises  about  I  ,V  or  2  inches  below 
the  ligament. 

The  common,  sujjerficial,  or  deep  femoral  may  be  the  seat  of 
aneurysm.  As  regards  the  common  trunk  there  is  little  trouble  in 
diagnosis,  as  the  usual  signs  are  well  marked  (Fig.  9).  It  is,  however, 
difficult  to  decide  whether  the  dilatation  is  situated  upon  the  super- 
ficial or  deep  branch.  If  the  pulsation  of  the  superficial  can  be  felt 
overlying  the  deep  vessel,  the  point  is  settled,  but  this  is  not  always 
possible.  It  is  well  to  remember  that  the  superficial  is  the  branch 
most  commonly  affected. 

Treatment. —  i.  Proximal  pressure;  2.  Ligation  If  in  Hunter's  canal, 
ligate  the  artery  higher  up ;  if  in  Scarpa's  triangle  or  if  the  profunda 
is  involved,  either  the  common  femoral  or  the  external  iliac  may  be 
tied. 

Popliteal  Aneurysm. — Landmarks. — A  line  drawn  down  the 
middle  of  the  ham  will  overlie  the  vessel.  The  guide  to  it  is  the 
outer  border  of  the  semi-membranosus  muscle,  under  whose  fleshy 
belly  the  artery  lies.  Pressure  upon  the  vessels  should  be  made 
against  the  bone  nearer  to  the  inner  than  the  outer  hamstring,  and 
considerable  force  is  required  to  obstruct  the  flow  of  blood. 

Next  to  the  aorta,  this  arteiy  is  the  most  common  seat  of  aneurysm. 
This  may  be  accounted  for  on  the  following  grounds  :  i.  The  artery  is 
more  subject  to  atheroma.  2.  It  is  but  slightly  supported  by  sur- 
rounding parts.  3.  It  is  readily  overstretched  by  undue  extension  of 
the  knee  and  compressed  by  forced  flexion.  4.  Embolus  is  liable  to 
lodge  in  it  from  the  fact  that  the  vessel  breaks  up  into  a  number  of 
branches.  Cases  are  not  infrequent  in  which  both  limbs  are  affected 
either  simultaneously  or  consecutively.  Both  fusiform  and  sacculated 
tumors  occur-,  but  the  latter  is  more  common.  The  progress  of  a 
popliteal  aneurysm  is  usually  rapid,  except  when  the  dilatation  takes 
place  on  the  front  of  the  artery  and  presses  against  the  bone,  in  which 
event  its  growth  is  slow. 

The  patient  who  is  the  subject  of  a  popliteal  aneurysm  has  probably 
complained  of  supposed  rheumatic  pain  in  his  knee,  with  stiffness  of 
the  joint  and  weakness  of  the  limb.  Next  a  swelling  is  observed,  and 
later  it  is  discovered  that  the  swelling  pulsates.  In  many  cases  the 
disease  develops  suddenly  as  the  result  of  some  violent  exertion.  The 
sac  is  easily  emptied  by  pressure  on  the  artery  above  the  tumor,  and 
distended  by  compression  on  the  distal  portion  of  the  vessel.  The 
bruit  is  distinct  and  runs  down  the  course  of  the  arter>^  If  the  sac 
becomes  filled  with  clots,  these  signs  may  be  wanting,  but  there  will 
still  be  the  history  of  a  time  when  pulsation  was  distinctly  felt,  and  in 
a  certain  proportion  of  cases  pulsation  ceases  to  return  after  a  greater 
or  less  time.  Synovitis  is  a  complication  likely  to  arise  when  the  sac 
presses  forward  against  the  joint.  This  aggravates  the  pain  and 
impairs  movement. 


EXAMINATION   OF   THE    VASCULAR   SYSTEM.  47 

Treatment. — Flexion,  proximal  compression,  elastic  bandage,  or 
ligature. 

Traumatic  Aneurysm. — In  the  forms  of  aneurysm  already  de- 
scribed the  starting-point  is  a  diseased  condition  or  an  overstretching 
and  partial  rupture  of  the  arterial  coats.  Traumatic  aneurysm  is  the 
result  of  a  direct  injury,  a  stab,  or  complete  rupture  of  the  artery,  with 
escape  of  its  contained  blood  into  the  surrounding  tissues  ;  that  is,  the 
formation  of  an  arterial  hematoma.  At  first  the  blood  may  escape 
freely  from  the  vessel,  but  as  it  infiltrates  the  tissues  the  pressure 
increases  until  it  cheeks  the  hemorrhage. 

The  symptoms  denoting  traumatic  aneurysm  are  the  formation  of  a 
pulsating,  painful  tumor  immediately  following  a  wound  or  injury  of  an 
artery  (Fig.  10).  The  bruit  is  generally  distinct,  and  the  pulsation  in 
the  artery  beyond  the  tumor  is  usually  lost.  Tension  is  a  marked 
symptom,  and  the  skin  shows  a  red,  inflammatory  character,  with 
increased  temperature. 

Should  pyogenic  organisms  gain  entrance,  the  formation  of  an 
abscess  will  result,  which  on  being  opened  is  attended  with  dangerous 
hemorrhage.  Besides  this  danger,  sloughing  and  even  gangrene  may 
occur  when  an  important  artery  is  the  seat  of  lesion  or  when  tension 
is  not  relieved. 


Fig.    10. — Diffuse  traumatic  aneurysm  of  the  brachial  artery  (White). 

Errors  in  diagnosis  may  be  made  by  mistaking  an  abscess  for 
aneurysm.  Although  the  resemblance  may  be  close,  we  must  remem- 
ber that  an  abscess  cannot  form  in  an  artery  as  an  immediate  result  of 
injury.  The  stages  of  inflammation  and  suppuration  must  take  several 
days,  while  traumatic  aneurysm  occurs  in  a  few  hours.  In  cases  of 
doubt  the  introduction  of  an  exploring  needle  will  settle  the  point. 

Treatment. — Apply  an  Esmarch  bandage  on  the  proximal  side  of 
the  aneurysm  and  cut  down  upon  the  tumor,  turn  out  the  clots,  divide 
the  vessel  completely  at  the  injured  points,  and  ligate  both  ends.  Dress 
the  wound  antiseptically.  If  the  aneurysm  is  so  situated  that  an 
elastic  bandage  cannot  be  applied,  dissect  down  upon  the  tumor,  make 
an  opening  large  enough  to  admit  the  finger,  and  search  for  the  bleed- 
ing point.  The  flow  of  warm  blood  will  act  as  a  guide  to  the  finger. 
When  the  opening  is  found  press  upon  it  to  stop  further  hemorrhage, 
enlarge  the  wound,  and  turn  out  the  clots.  Now  by  means  of  an 
aneurysm  needle  pass  a  catgut  ligature  around  the  artery  above,  and 
another  below  the  point  compressed  by  the  finger.  In  gunshot  wounds 
especially,  when  the  aneurysm  is  on  one  of  the  arteries  of  an  extremity 
or  when  a  large  artery  is  involved  near  the  trunk,  and  the  blood-supply 
to  the  limb  is  evidently  cut  off,  rendering  gangrene  inevitable,  amputa- 
tion is  the  proper  treatment. 


48  SrRG/C.IL    DLU;X0S/S   .I.V/)    JRKATMKNr. 

Other  blood-tumors  bcann<;  a  close  relation  to  aneurysm,  but  not 
falling  strictly  within  the  definition,  are  certain  tumors. 

Cirsoid  iriii'iirvsin  is  a  tumor  consisting  of  a  number  of  small-sized 
arteries  elongated  and  dilated.  The  tumor  is  soft,  bluish  in  color, 
irregular  in  shape,  and  pulsating.  It  is  always  superficial,  and  is 
readily  distinguished  from  true  aneurysm. 

Arterial  varix  is  to  an  artery  what  a  varicose  condition  is  to  a  vein. 
It  is  a  single  small  artery  dilated  and  elongated. 

Anairysnial  varix  is  a  communication  between  an  artery  and  a  \ein 
without  the  intervention  of  a  sac.  We  do  not  see  it  often  now-a-days, 
but  in  the  good  old  days  when  bleeding  was  universal  the  condition  was 
quite  common.  If,  instead  of  opening  the  vein  alone,  an  unskilful 
operator  incised  both  artery  and  vein,  and  then,  as  was  the  custom, 
applied  a  firm  compress  to  arrest  hemorrhage,  an  aneurysmal  varix  was 
a  common  result.  It  occurs  in  this  wise :  By  inflammatory  action  the 
artery  and  the  vein  become  adherent,  leaving  the  wound  in  each  still 
permeable,  allowing  arterial  blood  to  pass  through  at  every  pulsation 
of  the  heart.  The  force  of  this  current  of  arterial  blood  against  the 
weak  wall  of  the  vein  causes  dilatation,  but  no  sac  is  formed.  A 
peculiar  bruit  attends  this  condition.  Prof  Spence  of  Edinburgh  was 
in  the  habit  of  comparing  it  to  the  sound  of  a  blue-bottle  fly  in  a 
paper  bag.  Valentine  Mott  compared  it  to  the  purring  of  a  kitten. 
Besides  the  bend  of  the  elbow,  aneurysmal  varix  may  affect  the  carotid 
and  internal  jugular  and  the  common  femoral  vessels. 

Treatment. — Many  cases  require  no  treatment,  except  an  elastic 
bandage  to  prevent  further  enlargement.  In  cases  attended  with  pain 
and  disturbance  of  the  circulation  pressure  at  three  points  may  be 
employed — viz.  on  the  artery  above,  on  the  vein  below,  and  over  the 
aneurysmal  varix.  This  failing,  operate  as  follows  :  Expose  the  varix 
by  dissection,  place  a  ligature  above  and  below  the  opening  in  both 
artery  and  vein,  and  cut  out  the  aneurysm. 

Varicose  Aneurysm. — It  is  always  puzzling  to  the  student  to 
distinguish  between  aneuiysmal  varix  and  varicose  aneurysm.  They 
are  alike  in  this  respect,  that  in  both  conditions  there  is  a  communication 
between  an  artery  and  a  vein.  Both  have  a  like  cause — that  is  to  say, 
a  wound  of  the  artery  and  the  vein.  The  results  of  that  wound,  how- 
ever, are  different.  In  aneurysmal  varix  the  walls  of  both  vessels 
become  adherent  and  there  is  no  sac.  There  is  really  no  aneurj^sm, 
and  you  will  notice  that  it  is  not  called  an  aneurysm.  It  is  the 
adjective  "  aneurysmal  "  that  is  employed.  In  varicose  aneurysm  a 
real  sac  is  formed  by  the  outpouring  of  blood  between  the  artery  and 
the  vein,  while  the  opening  in  both  vessels  remains  as  in  the  former 
case.  It  is  a  real  aneur>'sm,  and  is  so  designated,  for  the  noun 
"  aneurysm  "  is  used. 

Treatment. — The  most  satisfactory  is  that  employed  by  Spence,  who 
cut  down  upon  the  artery  above  the  sac,  and  also  below  it,  ligating  the 
artery  at  each  position.  This  operation  shuts  off  the  current  from  the 
sac  and  allows  coagulation  to  take  place. 


INJURIES  AND  DISEASES   OF  THE    OSSEOUS  SYSTEM.  49 

CHAPTER   III. 

INJURIES   AND    DISEASES   OF   THE   OSSEOUS   SYSTEM. 

Ix  examining  the  osseous  system  we  shall  consider  fractures,  dis- 
locations, inflammations  of  bone,  tumors  of  bone,  and  deformities. 

I.  FRACTURES. 

As  a  rule,  the  diagnosis  of  fractures  is  not  difficult.  In  many  cases 
the  diagnosis  is  made  by  the  patient  or  his  friends  before  the  arrival  of 
the  surgeon.  This  is  usually  the  case  in  fracture  of  the  femur,  the 
humerus,  or  both  bones  of  the  forearm  or  of  the  leg.  There  are  some 
fractures,  however,  which  require  considerable  skill  and  judgment  to 
decide  upon  their  nature,  owing  to  the  obscurity  of  the  symptoms,  the 
amount  of  swelling,  and  the  position  of  the  bone. 

As  fractures  come  into  the  class  of  cases  which  we  may  designate 
as  emergencies,  I  shall  take  this  opportunity  to  say  a  few  words  upon 
emergency  cases  in  general. 

An  accident,  as  a  rule,  creates  a  panic.  Everybody  "  loses  his 
head,"  and  the  young  surgeon  is  often  perplexed  and  embarrassed. 
When  a  messenger  summons  you  to  such  a  case  do  not  allow  his 
haste  to  disconcert  you.  Compel  him  to  take  time  to  tell  you  the 
three  following  things  :  i.  The  correct  name  and  address  of  the  injured 
person,  which  you  must  carefully  write  down ;  2.  Whether  or  not  he 
has  been  removed  from  the  scene  of  the  accident ;  3.  W^hat  the  nature 
of  the  injury  is.  Sometimes  the  messenger  will  tell  you  he  ran  off  in 
such  a  hurry  that  he  did  not  wait  to  ask  what  had  happened.  As  a 
rule,  howev^er,  he  can  giv-e  some  idea  of  the  condition  of  things.  He 
can  tell  whether  the  injured  person  is  bleeding  and  whether  he  is  con- 
scious. If  he  can  state  how  and  under  what  circumstances  the  accident 
occurred,  the  surgeon  can  form  a  fairly  correct  idea  as  to  the  proba- 
bility of  fracture  or  dislocation.  These  inquiries  need  occupy  but  a  few 
moments,  and  frequently  sav'e  much  time  and  annoyance. 

A  business-like  young  surgeon  will  always  have  his  satchel  well 
stocked  and  ready  for  emergencies.  He  should  have  in  it  at  least  the 
following :  Needles,  prepared  catgut,  corrosive-sublimate  tablets,  iodo- 
form and  sublimate  gauze,  absorbent  cotton,  a  few  bandages,  two 
bistouries,  six  hemostatic  forceps,  a  pair  of  scissors,  a  male  catheter,  a 
hypodermic  syringe,  a  bottle  of  chloroform,  Esmarch's  inhaler,  a  4  per 
cent,  solution  of  cocain,  a  half  ounce  of  collodion,  a  razor,  a  nail-brush, 
and  two  plaster-of-Paris  bandages. 

When  the  patient  has  not  been  removed  from  the  scene  of  the 
accident  before  the  arrival  of  the  surgeon,  a  brief  examination  must 
be  made  to  ascertain  the  character  of  the  injuries.  If  hemorrhage  be 
profuse  and  a  vessel  of  considerable  size  be  wounded,  a  tourniquet 
may  be  applied  temporarily  until  the  patient  is  removed  to  his  home 
or  to  a  hospital.  If  a  limb  be  fractured  or  severely  lacerated,  a  tem- 
porary splint  must  be  applied.  The  patient  may  complain  of  cold,  and 
no  amount  of  clothing  heaped  upon  him  can  make  him  comfortable. 


50 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


A  hypodermic  of  morphine  acts  speedily  and  effectually,  allaying  pain, 
causing  the  patient  to  feel  a  sensation  of  warmth  and  comfort.  It  is 
also  an  excellent  remedy  for  shock — better  than  alcoholic  stimulants. 

If  the  patient  be  unconscious,  place  him  on  his  back  with  the  head 
slightly  raised,  care  being  taken  to  give  the  lungs  free  play  by  unbutton- 
ing the  clothing  over  the  chest  and  removing  the  neckwear. 

The  utmost  care  should  be  observed  in  moving  the  injured  person. 
In  a  fracture  of  the  lower  extremity  the  fragments  are  liable  to  lacerate 
the  tissues  or  may  even  perforate  the  skin,  thus  converting  a  simple 
into  a  compound  fracture.  One  attendant  should  support  the  fractured 
limb,  and  before  transporting  the  patient  on  a  stretcher  the  two  limbs 
should  be  tied  together  to  prevent  the  injured  member  from  rolling 
outward  by  its  own  weight,  or  a  blanket  or  coat  may  be  rolled  up  and 
placed  against  the  outside  of  the  limb  as  a  support. 

Arrived  at  the  sick-room,  the  surgeon  will  find  it  to  his  advantage 
to  select  two  or,  if  necessary,  three  of  the  most  intelligent  of  the 
bystanders,  while  he  quietly  but  firmly  asks 
all  the  rest  to  retire.  This  will  relieve  him  of 
a  crowd  of  critical  observers,  while  the  favored 
few  who  are  asked  to  remain,  feeling  that  a 
compliment  has  been  paid  them,  fall  into  line 
as  willing  helpers. 


Fig.  II. — Partial  or  green-stick  frac- 
ture of  the  radius  (Stimson). 


Fig.  12. — Transverse  fracture  of 
the  femur  (Gurlt). 


In  removing  clothing  the  sound  arm  should  be  slipped  out  of  the 
sleev^e  first,  after  which  the  injured  arm  can  be  liberated  without  much 
trouble.  In  cases  where  much  pain  is  suffered  the  scissors  can  be  used 
to  rip  up  seams  and  remove  the  garments  with  the  least  disturbance 
possible. 

Classification  of  Fractures. — Fractures  are  classified  as  fol- 
lows : 

I.  Incoinplctc  Fractures. — This  class  comprises  fissures  of  flat  bones, 
such  as  those  of  the  cranium,  in  which  the  line  of  fracture  does  not 
extend  completely  across  the  bone  nor  through  its  entire  thickness.     It 


lAy CRIES  AND  DISEASES   OF  THE    OSSEOUS  SYSTEM. 


51 


can  also  occur  in  long  bones  when  the  continuity  has  not  been  entirely 
lost,  as  in  the  so-called  "green-stick"  fracture  (Fig.  11).  Then  there 
may  be  a  simple  depression  of  a  part  of  a  bone  as  when  a  blow  is 
received  upon  the  head  which  bends  a  portion  of  the  bone  inward. 
The  separation  of  a  splinter  of  bone  or  of  an  apophysis  is  sometimes 
spoken  of  as  an  incomplete  fracture.  We  often  hear  of  a  bone  being 
simply  splintered,  but,  as   rule,  such  a  diagnosis  is  evidence  of  doubt 


Fig.  13. — Oblique  fracture  of  the  clavicle  (Stimsdn). 


in  the  mind  of  the  surgeon  as  to  the  existence  of  fracture.  When  a 
bone  is  splintered,  it  is  usually  by  direct  violence,  as  in  the  case  of  a 
sword  or  bullet  wound.  The  forcible  contraction  of  a  muscle  may 
splinter  a  bone  at  the  point  of  insertion  of  the  muscle. 

2.  Complete  Fractures. — In  this  variety  there  is  a  complete  breach 
of  continuity  of  the  bone.  According  to  the  direction  of  the  line  of 
fracture  it  is  spoken  of  as  transverse  (Fig.  12),  oblique  (Fig.  13),  longi- 


FlG.  14. — Intercondyloid  fracture  of  the 
humerus  (Stimson). 


Fig.  15. — Comminuted  perforating 
gunshot  fracture  of  the  head  of  the 
humerus  (Army  Med.  Mus.). 


tudinal,  toothed,  V-shaped  or  T-shaped.  When  the  seat  of  fracture  is 
taken  into  consideration,  we  speak  of  fracture  of  the  neck,  shaft,  con- 
dyle, etc.  When  in  the  vicinity  of  a  joint  the  fracture  is  spoken  of  as 
intracapsular  (within  the  capsular  ligament),  extracapsular  (without  the 
capsule),  or  when  extending  into  the  joint  as  intra-articular.  The 
most  common  example  of  this  is  in  longitudinal  fracture  of  the  lower 
end  of  the  humerus,  when  the  fracture  extends  into  the  elbow-joint 


52  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

(Fig.  14).  When  a  bone  is  broken  into  a  number  of  fragments  it  is 
said  to  be  comminuted  (Fig.   15). 

3.  Couipouud  fractures,  in  which  the  broken  bone  communicates 
with  the  exterior  through  a  wound  of  the  soft  parts. 

Diagnosis  of  Fractures  in  General. — In  taking  the  history 
of  the  case — which  in  the  first  instance  may  be  oral — care  should  be 
taken  to  note  the  nature  and  direction  of  the  force  which  caused  the 
injury.  Fractures  occur  by — i.  Direct  violence,  as  when  a  falling 
body  strikes  the  clavicle,  fracturing  the  bone.  2.  Indirect  violence,  as 
when  a  person  falls,  the  shoulder  first  striking  the  ground  and  thus 
fracturing  the  clavicle.  3.  Contre-coup,  as  when  a  blow  upon  the 
head  causes  fracture,  not  at  the  point  of  contact,  but  at  the  opposite 
point  of  the  skull.  4.  Muscular  action,  as  when  the  patella  is  broken 
by  powerful  contraction  of  the  quadriceps.  A  violent  effort  in  throw- 
ing a  ball  has  broken  the  humerus,  and  a  desperate  kick  at  a  dog, 
which  all  too  nimbly  gets  out  of  harm's  way,  has  been  known  to  frac- 
ture the  femur.  Forcibly  throwing  the  head  backward  has  broken  the 
neck.  The  ribs  have  been  broken  by  violent  coughing,  and  the  ster- 
num during  the  pains  of  labor.  The  coracoid  process  has  been 
wrenched  off  by  the  contractions  of  the  coraco-brachialis,  pectoralis 
minor,  and  short  head  of  the  biceps  ;  so  has  the  posterior  part  of  the 
calcaneum  by  the  action  of  the  muscles  of  the  calf 

The  evidences  necessary  to  prove  the  existence  of  a  fracture  are — 
I.  Deformity;   2.  Abnormal  mobility ;     3.  Crepitus. 

Make  your  examination  gently  and  systematically ;  at  the  same 
time,  do  not  allow  your  fear  of  causing  pain  to  prevent  your  satisfying 
yourself  as  to  the  real  condition.  The  patient  who  makes  a  loud  out- 
cry when  you  try  to  elicit  crepitus  will  be  just  as  ready  to  cry  out 
against  your  reputation  should  you  make  a  mistake  in  diagnosis. 
Take  the  sound  limb  for  a  model,  and,  comparing  the  injured  member 
with  it,  satisfy  yourself  upon  the  following  questions  : 

I.  Is  there  deformity?  In  many  cases  a  glance  will  settle  this 
point.  When  a  long  bone,  such  as  the  femur,  is  broken,  an  angle  more 
or  less  obtuse  is  formed  by  the  fragments,  and  the  segments  of  the 
limb  show  a  corresponding  change  in  direction.  When  the  fragments 
slip  past  each  other  there  may  be  seen  a  bunching  caused  by  the  con- 
traction of  the  muscles,  and  the  limb  is  shortened. 

To  satisfy  ourselves  more  thoroughly  on  this  point  measurements 
should  be  made.  In  the  forearm  and  the  leg  both  ends  of  the  bones 
can  be  felt  and  the  measuring  tape  applied.  In  measuring  the  femur 
fixed  points  on  other  bones  must  be  taken.  Place  the  patient  flat 
upon  his  back  with  both  limbs  close  together  and  perfectly  straight. 
Apply  the  tape  to  the  anterior  superior  spinous  process  of  the  ilium, 
and  carry  it  down  to  the  top  of  the  inner  malleolus.  In  the  case  of  the 
humerus  the  acromion  process  is  taken  as  a  fixed  point,  and  the  tape 
carried  to  the  lowest  point  on  the  external  condyle.  It  must,  however, 
be  borne  in  mind  that  in  many  persons  there  is  a  difference  in  the  length 
of  the  limbs  which  may  be  unknown  to  the  persons  themselves.  This 
rarely  amounts  to  more  than  a  quarter  of  an  inch,  but  in  some  instances 
it  reaches  an  inch  or  even  more.  Another  source  of  possible  error  is 
previous  disease  or  injury  which  may  have  shortened  one  of  the  limbs. 


INJURIES  AND   DISEASES   OF  THE    OSSEOUS  SYSTEM.  53 

Swelling  is  an  almost  constant  accompaniment  of  fracture  and  a 
source  of  deformity.  It  is  often  attended  with  heat  and  redness.  On 
the  second  or  third  day  large  blebs,  filled  at  first  with  a  yellow  and 
later  with  a  bloody  liquid,  sometimes  appear.  These  are  more  apt  to 
occur  in  fractures  of  the  leg  and  forearm.  Fractures  caused  by  direct 
v^iolence  are  liable  to  have  injury  of  the  soft  parts,  either  immediate  or 
showing  at  a  later  period  in  the  form  of  sloughing.  Fractures  by 
indirect  violence  are  often  followed  by  extravasations  of  blood  beneath 
the  skin  (ecchymoses),  and,  as  a  rule,  at  some  distance  from  the  seat 
of  fracture. 

2.  Is  there  preternatural  mobility  ?  If  a  joint-like  movement  is 
found  in  the  shaft  of  a  long  bone,  the  evidence  of  fracture  is  complete. 
When  the  bone  is  broken  near  one  or  other  extremity,  however,  this 
abnormal  mobility  is  not  so  easily  recognized.  A  fracture  at  or  near 
a  joint  may  be  attended  with  an  abnormal  range  of  movement  of  the 
joint  or  with  a  mov^ement  in  an  unnatural  direction. 

3.  Is  there  crepitus  ?  This  is  a  pathognomonic  sign  of  fracture. 
It  is  the  rough,  grating  sensation  which  is  conveyed  to  the  ear  and 
hand  of  the  surgeon,  and  with  accentuated  force  to  the  feelings  of  the 
patient,  when  the  broken  ends  of  a  bone  are  rubbed  together.  Crepitus 
is  discovered  by  grasping  the  bone  firmly  above  and  below  the  seat  of 
fracture,  and  causing  sufficient  movement  of  the  fragments  against  each 
other  to  produce  the  grating  sensation  already  described.  The  moment 
this  is  found  cease  further  manipulation,  for  it  will  only  do  harm. 
Indeed,  in  some  fractures  we  should  not  try  to  find  crepitus  ;  in  others 
we  cannot  find  it  if  we  try.  In  fracture  of  the  neck  of  the  femur  with 
impaction  we  shall  do  positive  injury  by  seeking  for  crepitus,  and  in 
immovable  fractures,  such  as  those  of  the  cranium,  crepitus  is  out  of 
the  question. 

4.  What  is  the  nature  of  the  displacement  ?  When  the  line  of  frac- 
ture is  transverse  to  the  long  axis  of  the  bone  it  is  called  a  transverse 
fracture,  and  the  displacement,  if  any,  is  lateral  or  it  may  be  overlapping. 
If  the  line  of  fracture  runs  for  some  distance  more  or  less  exactly  in 
the  same  direction  as  the  long  axis,  it  is  called  a  longitudinal  fracture, 
and  in  that  case  there  is  usually  no  displacement.  The  direction  of  the 
fracture  may  be  intermediate  between  these  two,  and  then  it  is  called 
oblique.  The  tendency  in  this  case  is  for  the  fragments  to  slip  past 
each  other,  causing  shortening  of  the  limb,  while  the  ends  of  the  bone 
cannot  be  so  distinctly  felt  as  when  there  is  a  transv^erse  fracture  with 
overlapping  of  the  fragments. 

The  discovery  of  the  Rontgen  or  x  rays  has  placed  in  our  hands  a 
most  satisfactory  means  of  diagnosing  a  fracture  and  of  demonstrating 
the  actual  position  of  the  fragments.  It  is  of  especial  value  in  fractures 
in  the  neighborhood  of  joints,  in  ununited  fractures  (see  Plate  I.),  and 
in  old  injuries  having  an  obscure  clinical  history. 

Besides  the  foregoing  signs,  which  are  objective,  there  are  certain 
subjective  symptoms  which  should  be  taken  into  account ;  these  are — 

{a)  Pain. — This  is  a  constant  accompaniment  of  fracture.  A  simple 
contusion  or  a  sprain  is  also  attended  with  pain,  and  you  may  often 
find  it  impossible  to  say  whether  the  injury  is  a  simple  bruise  or  a 
fracture.     The  safe  rule  in  such  a  case  is  to  give  yourself  and  patient 


54  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

the  benefit  of  the  doubt  and  treat  it  as  a  fracture.  Perfect  immobiliza- 
tion in  splints  is  excellent  treatment  for  a  contusion  or  a  sprain.  The 
removal  of  the  apparatus  on  the  second  or  third  day  will  i)robabIy  show 
the  case  in  a  new  li^ht,  with  swellini^  abated  and  pain  absent.  Then,  if 
you  can  satisfy  yourself  that  the  bones  are  unbroken,  your  error  has  been 
on  the  side  of  safety.  Pain,  to  be  of  any  value  to  us  as  a  symptom  of 
fracture,  must  be  constant  and  limited  to  one  particular  spot.  If  after 
a  severe  wrench  of  the  foot,  pain  is  felt  over  the  fibula  an  inch  or  two 
above  the  ankle,  much  increased  on  pressure,  even  if  every  other 
symptom  is  wanting,  we  are  justified  in  diagnosing  a  fracture.  When 
pressure  upon  one  point  of  a  rib  causes  pain  at  another  point,  the  evi- 
dence is  strongly  in  favor  of  fracture. 

(/;)  Hciplcss)icss  of  the  Part. — As  a  rule,  the  patient  can  make  no 
use  of  a  fractured  limb.  The  least  motion  causes  suffering,  so  that 
pain  or  the  fear  of  it  compels  him  to  keep  the  part  at  perfect  rest. 
This  has  a  salutary  influence,  for  the  movement  of  a  fracture  may  be 
attended  with  considerable  danger.  A  person  suffering  from  fracture 
of  the  tibia  may,  by  attempting  to  walk,  force  the  fragments  past  each 
other  and  out  through  the  skin,  thus  convertisg  a  simple  into  a  com- 
pound fracture.  The  same  is  liable  to  happen  in  fracture  of  the  fibula 
or  of  the  clavicle.  If  there  be  marked  impaction,  or  if  the  periosteum 
remain  intact,  or  if  one  of  a  pair  of  bones  is  broken,  it  is  possible  for 
the  patient  to  use  the  limb.  I  had  a  patient  who  walked  several  hun- 
dred yards  after  sustaining  fracture  of  the  neck  of  the  femur,  which 
was  firmly  impacted,  and  cases  are  reported  of  persons  walking  about 
for  days  in  the  same  condition.  In  some  cases  of  fracture  of  the 
clavicle  it  is  possible  for  the  person  to  raise  the  arm  above  the  head 
on  the  affected  side. 

Errors  in  diagnosis  are  liable  to  occur  by  our  not  distinguishing 
between  fractures,  separation  of  epiphyses,  dislocations,  contusions, 
and  sprains. 

The  greatest  difficulty  arises  when  the  injury  is  in  the  neighborhood 
of  a  joint,  and  especially  when  there  has  been  time  for  swelling  to  take 
place.  Another  disturbing  element  is  the  presence  of  previous  disease 
in  the  joint,  such  as  synovitis  or  rheumatoid  arthritis. 

{a)  Separation  of  Epiphyses. — This  occurs  in  young  children  :  the 
injury  is  near  the  extremity  of  the  bone ;  when  crepitus  can  be  felt  it 
is  of  a  softer  character  than  that  which  is  found  in  fracture ;  in  infants 
crepitation  is  wanting.  The  displacement  is  slight,  for,  as  a  rule,  the 
periosteum  remains  intact  and  steadies  the  separated  epiphysis.  When 
the  bone  is  near  the  skin  its  end  can  be  felt,  and  it  is  rounded  and 
smooth,  not  sharp  and  rough  as  in  fracture.  The  most  important 
practical  point  in  the  diagnosis  of  this  accident  is  that  separation  of  an 
epiphysis  is  liable  to  be  followed  by  arrest  of  development.  Repair 
usually  takes  place  by  osseous  tissue ;  hence  the  bone  ceases  to  grow 
at  the  injured  end,  and  if  the  patient  has  not  completed  his  growth 
permanent  shortening  will  result.  In  a  case  which  came  under  my 
observation  the  femur  was  shortened  one  inch  and  a  half  in  a  young 
man  sixteen  years  of  age,  who  sustained  this  injury  w^hen  a  child.  In 
a  single  long  bone,  such  as  the  femur  or  humerus,  this  shortening  is 
not  so  serious  as  when  it  occurs  in  one  of  a  pair.     When  the  accident 


INJURIES  AND  DISEASES   OF   THE    OSSEOUS  SYSTEM.  55 

occurs  at  the  lower  end  of  the  radius,  an  arrest  of  development  fol- 
lows, the  styloid  process  of  the  ulna  becomes  abnormally  prominent, 
the  use  of  the  hand  is  seriously  interfered  with,  and, a  most  disagree- 
able deformity  is  the  result.  If  our  diagnosis  is  separation  of  the  epiph- 
ysis, this  danger  should  be  pointed  out  to  the  friends  of  the  little  patient. 

{p)  Dislocation. — Except  in  the  presence  of  considerable  swelling  the 
diagnosis  between  fracture  and  dislocation  is  not  difficult.  In  disloca- 
tion the  joint  is  fixed,  and  cannot  be  moved  except  by  force.  When 
the  deformity  is  rectified  there  is  no  tendency  for  it  to  return.  True 
crepitus  is  wanting.  It  may  be  simulated  by  joint  crepitus,  effusion 
into  the  sheaths  of  tendons,  emphysema,  and  by  the  grating  of  osteo- 
phytes in  chronic  osteo-arthritis.  True  crepitus,  having  once  been  felt, 
can  hardly  afterward  be  mistaken  by  the  surgeon.  The  greatest  dif- 
ficulty will  arise  at  the  elbow  in  cases  where  both  dislocation  and 
fracture  exist. 

{c)  Contusions. — The  pain  and  helplessness  caused  by  a  severe  con- 
tusion may  closely  simulate  a  fracture  or  a  dislocation.  The  pain,  or 
fear  of  it,  compels  immobility,  and  the  rigidity  of  the  muscles  about  a 
joint  under  these  circurfistances  is  puzzling.  Putting  the  patient  under 
an  anesthetic  will  greatly  help  us  by  relieving  muscular  contraction 
and  pain. 

If,  in  spite  of  a  painstaking  examination,  yon  arc  still  unccrtai)i,  treat 
the  case  as  a  fracture  and  Zt'ait  for  tzuo  or  three  days. 

Complications  of  Fracture. — There  are  numerous  conditions 
which  may  complicate  fracture.  They  may  be  considered  under  three 
heads : 

I.  Complications  due  to  a  General  Effect  upon  the  System. — Of  these 
the  most  important  is  shock.  The  violence  which  causes  fracture  may 
be  so  severe  as  to  affect  the  nervous  system  seriously,  not  only  on 
account  of  injury  to  the  bone,  but  to  the  soft  parts  as  well.  The  ner- 
vous excitement  and  mental  condition  also  play  an  important  part. 
Shock  is  readily  recognized  by  coldness  of  the  skin  and  pallor  of  the 
face ;  frequent,  irregular  pulse,  the  artery  appearing  to  empty  itself 
after  each  beat.  The  temperature  is  below  normal,  and  may  go 
down  to  95°  or  94°   F.     The  breathing  is  shallow. 

Fever  very  frequently  follows  a  fracture,  and  may  partake  of  the 
character  of  fermentative  or  traumatic  fever,  due  to  the  extravasation 
of  blood  and  the  absorption  of  the  blood-ferment  set  free  by  the 
injured  tissues.  The  temperature  rises  to  about  100°  or  101°  F.  by  the 
evening  of  the  second  day,  and  is  identical  with  the  fever  which  follows 
aseptic  surgical  operations.  In  the  case  of  compound  fractures,  where 
suppuration  is  allowed  to  take  place,  the  character  of  the  fever  is 
different  and  is  persistent. 

Retention  of  urine  is  a  complication  to  be  watched  for,  particularly 
in  fractures  about  the  pelvis.  A  catheter  should  always  be  passed  ;  if 
instead  of  urine  a  little  blood  escapes,  while  the  patient  states  that  the 
bladder  was  full  at  the  time  of  the  accident,  we  may  infer  that  the  blad- 
der is  ruptured.  If,  however,  the  rent  in  the  bladder  is  small  or  occluded 
by  a  loop  of  intestine,  clear  urine  may  collect  in  the  bladder  and  come 
away  through  the  catheter. 

Fat-embolism  is,  fortunately,  a  rare  complication.     In  the  process  of 


56  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

repair  fatty  degeneration  takes  place  in  the  medulla,  and  perhaps  in  the 
subcutaneous  tissue.  Under  ordinary  circumstances  and  in  the  vast 
majority  of  cases  this  gives  rise  to  no  symptoms.  Hut  it  occasionally 
happens  that  through  the  open  mouths  of  veins  which  have  been  torn 
across  a  large  number  of  these  broken  fat-cells  are  taken  up  and  car- 
ried back  to  the  right  side  of  the  heart,  and  from  there  sent  to  the 
lungs.  The  symptoms  produced  are  collapse,  coming  on  after  an 
interval  of  several  days  and  not  immediately,  as  is  the  case  in  shock. 
It  is  a  sort  of  secondary  shock.  The  earliest  indications  are  transient 
attacks  of  dyspnea  with  irregularity  of  the  heart-beat,  and  in  some 
cases  slight  hemoptysis.  The  pulse  is  small  and  rapid,  and  the  breath- 
ing shallow  and  sighing  in  the  advanced  stage,  running  into  the  Cheyne- 
Stokes  respiration.  The  mind  becomes  dull,  weakness  increases,  and 
in  many  cases  convulsions  intervene  before  the  approach  of  death. 

2.  Complications  Due  to  Confinement  of  the  Patient  to  his  Bed. — 
Except  in  those  suffering  from  other  diseases  or  debilitated  from  age 
the  confinement  necessary  during  the  repair  of  fracture  is  well  borne. 
Constipation  is  very  common,  varying  in  degree  from  a  simple  inactiv- 
ity to  obstinate  constipation,  attended  with  jaundice  or  gout.  Con- 
gestion of  the  lungs  is  likely  to  appear  in  old  or  feeble  persons  whose 
circulation  is  languid  and  who  cannot  bear  to  remain  long  in  the  re- 
cumbent posture.  Bed-sores  constitute  one  of  the  most  troublesome 
and  distressing  complications  ;  they  appear  only  in  the  debilitated.  The 
sacrum  is  the  most  common  position,  but  they  may  occur  over  any  of 
the  bony  prominences  where  pressure  is  made  either  by  the  weight  of 
the  patient  or  by  ill-adjusted  splints.  Cleanliness  is  of  the  utmost 
importance  in  the  prevention  of  bed-sores.  The  use  of  an  air-cushion 
is  also  a  great  help,  and  when  it  can  be  possibly  avoided  the  aged  and 
feeble  should  not  be  treated  by  rigid  confinement. 

3.  Local  Complications. — Laceration  of  the  soft  parts  occurs  to  a 
greater  or  less  degree  in  almost  every  fracture.  Attending  this  lacera- 
tion is  extravasation  of  blood,  but  except  when  this  is  severe  no  atten- 
tion need  be  paid  to  it.  The  torn  tissues  speedily  undergo  repair  and 
collections  of  blood  are  rapidly  absorbed.  Even  when  a  considerable 
quantity  of  blood  is  poured  out,  forming  a  hematoma  and  raising  the 
skin  above  the  subjacent  tissues,  simple  pressure  and  patience  will 
bring  the  parts  back  to  their  natural  condition.  When,  however,  a 
larger  vessel  is  torn,  we  have  what  is,  practically,  a  traumatic  aneurysm, 
and  it  must  be  treated  as  such.  As  long  as  the  parts  can  be  kept  in 
an  aseptic  condition  a  moderate  amount  of  extravasation  of  blood  is 
not  serious,  but  in  compound  fractures  especially,  where  infection  of 
the  wound  may  occur,  it  adds  a  dangerous  element.  Simple  fractures 
may  also  become  infected  by  absorption  of  septic  material  through  a 
bruised  skin  covering,  as  in  a  case  of  direct  violence  in  which  cleanli- 
ness has  been  neglected.  Dead  blood-cells  and  lacerated  tissues  form 
a  most  fertile  culture-soil  for  septic  bacteria.  Where  such  collections 
can  be  got  at  in  compound  fractures,  they  should  be  carefully  washed 
out  and  drained.  If  they  extend  along  the  limb,  enlarge  the  opening 
and  make  incisions  if  necessary. 

Laceration  or  rupture  of  the  main  arterial  trunk  of  the  limb  is  a 
most  serious  complication.     The  most  common  accident  of  this  kind 


INJURIES  AND  DISEASES   OF  THE    OSSEOC'S  SYSTEM  $y 

occurs  when  the  lower  end  of  the  femur  is  fractured  and  one  of  the  frag- 
ments is  driven  backward  upon  the  popHteal  artery.  Even  when  the 
bone  fails  to  cut  through  the  vessel,  the  inner  and  middle  coats  of  the 
artery  may  be  ruptured,  curling  themseh^es  up  within,  and  the  vessel 
thus  weakened  gives  way  at  a  later  period.  Sometimes  the  rupturing 
of  the  inner  and  middle  coats  may  favor  the  formation  of  a  clot ;  in 
such  a  case  hemorrhage  rarely  occurs.  When  an  arterial  trunk  is  thus 
divided  the  symptoms  develop  rapidly.  Swelling  of  a  tense  elastic 
character,  steadily  increasing,  pain  that  is  frequently  excruciating,  pul- 
sation above,  but  none  in  the  artery  below  the  injury,  rendering  the 
limb  cold,  edematous,  and  benumbed, — these  are  the  prominent  symp- 
toms. When  there  is  a  wound  the  blood  flows  freely,  coming  in  jets 
when  the  opening  is  large  and  the  vessel  exposed,  but  when  the  exter- 
nal wound  is  small  and  tortuous  the  blood  may  come  away  in  a  steady 
stream. 

In  compound  fractures  when  a  large  vessel  is  torn  we  have  two 
courses  before  us — either  to  find  and  ligate  the  vessel  above  and  below 
the  laceration,  or,  failing  in  this,  to  amputate  the  limb.  Bleeding  under 
such  circumstances  is  difficult  to  check.  In  fractures  by  direct  violence 
we  expect  more  laceration  than  in  those  caused  in  other  ways.  The 
crushing  of  the  soft  parts,  as  when  a  car-wheel  runs  over  a  limb,  de- 
stroys not  only  the  main  vessel,  but  the  collateral  circulation.  The 
skin,  owing  to  its  toughness  and  greater  resisting  power,  may  seem 
but  little  the  worse  of  the  bruise.  Do  not  be  deceived  by  this,  for  the 
vessels  and  nerves  may  be  utterly  destroyed. 

Treatment  of  Lacerated  Arteries. — Place  a  tourniquet  upon  the  limb. 
Enlarge  the  wound  and  find  the  bleeding  point.  It  is  always  difficult 
to  find  an  arter}^  that  is  torn  in  this  manner.  If  the  vessel  cannot  be 
found  in  the  wound,  it  is  of  no  use  to  ligate  it  higher  up,  for,  if  the 
collateral  circulation  be  good,  bleeding  will  continue  ;  if  the  collateral 
circulation  cannot  be  maintained,  gangrene  is  a  certain  consequence. 
We  should,  however,  give  a  fair  trial  to  compression  of  the  vessel 
higher  up,  for  it  will  settle  the  question  of  collateral  circulation,  and  in 
many  cases  it  has  been  successful  in  permanently  arresting  the  hemor- 
rhage. 

In  simple  fracture,  when  we  can  feel  that  the  circulation  is  not  com- 
pletely arrested,  the  limb  retaining  its  warmth  and  sensation,  it  is  best  to 
wait.  The  bleeding  may  cease,  owing  to  pressure  of  the  tissues,  or  the 
wound  in  the  artery  may  close  and  the  extravasated  blood  become 
absorbed.  The  limb  should  be  placed  in  an  deviated  position,  wrapped 
in  cotton  to  maintain  an  even  temperature,  and  only  such  bandages  and 
splints  applied  as  are  necessary  to  keep  the  parts  at  perfect  rest  with 
gentle  compression. 

If,  however,  the  limb  is  found  to  be  cold,  the  artery  below  the 
injury  pulseless,  and  the  swelling  tense  and  rapidly  spreading,  it  is 
evident  that  gangrene  will  supervene,  and  the  only  course  is  to 
amputate. 

Rupture  of  veins  is  rare.  A  fracture  of  the  clavicle  sometimes  tears 
the  subclavian  vein,  and  the  popliteal  vein  has  been  ruptured  by  a  frag- 
ment of  the  femur.  But,  as  a  rule,  the  veins  escape  much  more 
frequently  than  the  arteries.     The  cases  in  which  they  suffer  are  those 


58  SURGICAL    DJAGXOSIS  AND    TREATMENT. 

in  which  the  injury  is  severe  and  both  arteries  and  veins  are  impHcated. 
The  symptoms  are  very  similar  to  those  ah'eady  mentioned,  with  the 
exception  of  pulsation.  The  treatment  consists  in  making  a  free  open- 
ing into  the  swelling,  turning  out  the  clots,  and  ligating  both  ends  of 
the  vein.  Thrombosis  and  embolism  are  also  complications  which 
must  be  taken  into  account.  In  one  case  reported  by  Southham 
thrombosis  appeared  on  the  seventeenth  day,  in  another  on  the  six- 
teenth, and  in  one  reported  by  Tyrrell  on  the  twelfth  day. 

Iiijiny  to  Ahi'vcs. — The  nerves,  owing  to  their  strength  and  tough- 
ness, are  seldom  injured  in  fracture.  A  nerve  may  slip  between  the 
fragments,  not  only  suffering  injury  itself,  but  preventing  the  union  of 
bone.  The  most  common  complication,  however,  is  at  a  later  stage, 
and  due  to  the  nerve  being  caught  in  the  callus,  which  in  the  process 
of  ossification  exerts  sufficient  pressure  to  cause  pain  and  interrupt  the 
nerve-function.  Of  all  the  nerves,  the  musculo-spiral  is  the  one  ^\•hich 
is  the  most  frequently  involved.  When  the  nerve  is  simply  irritated 
the  symptoms  are  neuralgia,  spasmodic  contraction,  and  hyperesthesia. 
When  the  nerve  is  compressed,  the  pain  is  constant,  and,  as  degeneration 
takes  place,  there  is  loss  of  power,  wasting,  and  diminished  sensibility. 

Diagnosis   and   Treatment   of    Special   Fractures. 

The  Nasal  Bones. — A  violent  blow  upon  the  nose,  followed  by 
copious  hemorrhage,  should  lead  us  to  suspect  fracture  of  the  nasal 
bones.  This  fracture  is  frequently  overlooked  both  by  patients  and 
surgeons.  The  swelling,  which  comes  on  rapidly,  obscures  the  symp- 
toms, and,  as  the  nose  is  a  very  sensitive  organ,  patients  are  often 
reluctant  to  submit  to  a  thorough  examination.  The  commonest 
situation  of  the  fracture  is  near  the  lower  ends  of  the  bones.  The 
fragments  are  driven  backward,  but  sometimes  they  are  found  to  be 
forced  to  one  side,  and  the  septum  is  frequently  involved.  The  fracture 
is  often  compound,  the  fragment  perforating  the  skin,  the  mucous  mem- 
brane, or  both.  Besides  local  pain,  there  are  severe  headache,  copious 
hemorrhage,  and  sometimes  emphysema  in  the  surrounding  cellular 
tissue. 

In  your  examination  look  for  deformity.  This  may  be  both  seen 
and  felt,  but  may  be  masked  by  swelling.  If  not  satisfied  with  an 
examination  of  the  external  parts,  look  into  the  nostrils,  and,  if  they 
are  filled  with  blood,  explore  them  gently  with  a  probe.  Crepitus  can 
be  felt,  but  usually  the  symptoms  are  clear  enough  without  this,  and 
the  manipulations  necessary  to  find  it  might  cause  further  laceration 
and  do  harm. 

Treatment. — If  properly  replaced,  fractures  of  the  nasal  bones  unite 
VQ.xy  rapidly.  Hippocrates  declared  that  perfect  union  took  place  in 
six  days.  Hamilton  relates  a  case  in  which  a  cure  was  effected  in 
seven  days. 

Take  a  small,  strong  instrument,  such  as  a  director  or  fine  sound, 
and  press  the  fragments  upward  from  the  inside,  while  the  finger  and 
thumb  of  the  other  hand  mould  the  parts  from  without.  It  must  be 
borne  in  mind  that  the  nasal  passage  at  the  point  where  pressure  is 
required  is  very  much  narrowed,  owing,  not  only  to  the  displaced  frag- 


INJURIES  AND   DISEASES   OF   THE    OSSEOUS  SYSTEM.  59 

merits,  but  also  to  the  swelling  in  the  mucous  membrane.  The  canal 
is  so  small  that  it  will  not  admit  objects  much  larger  than  a  probe.  A 
lead  pencil  or  an  instrument  wrapped  in  cotton  is  not  suitable.  When 
such  is  used,  it  is  stopped  before  it  reaches  the  point  at  which  pressure 
is  required,  and  the  operator  pushes  upward  against  the  nasal  process 
of  the  superior  maxilla.  Finding  a  resistance  which  cannot  be  over- 
come, he,  after  repeated  attempts,  leaves  the  case  with  the  bones  un- 
reduced. When  the  fragments  do  not  remain  in  position  after  being 
replaced,  a  nickel-plated  needle  may  be  passed  through  the  nose  from 
side  to  side  just  below  the  fractured  bones,  and  the  parts  held  in  place 
by  a  rubber  band  crossing  the  nose  from  one  end  of  the  needle  to  the 
other. 

Hemorrhage  can  be  stopped  by  injecting  the  nares  with  ice-cold 
water  or  by  the  application  of  an  ice-bag.  If  the  hemorrhage  cannot 
be  thus  controlled,  the  posterior  nares  should  be  plugged.  A  good 
method  of  effecting  this  is  either  by  the  india-rubber  inflating  tampon 
or  by  the  assistance  of  Bellocq's  sound.  By  the  former  method  the 
india-rubber  tube  which  is  used  has  two  dilatations  upon  it,  so  shaped 
that  when  inflated  they  accurately  fill  the  posterior  and  anterior  nares  re- 
spectively. It  is  passed  in  while  flaccid  by  means  of  a  long  probe,  and 
inflated  when  in  position  by  means  of  a  small  syringe  or  by  the  mouth. 
Reinflation  is  necessary  from  time  to  time.  By  the  latter  method  a 
pledget  of  lint  or  cotton-wool  rather  larger  than  the  aperture  to  be 
filled  is  taken,  and  round  the  middle  of  this  is  tied  a  doubled  piece  of 
stout  thread,  a  long  loop  being  thus  left  on  one  side  and  two  ends  on 
the  other,  one  of  which  is  cut  off  short.  The  sound  is  then  armed 
with  a  separate  length  of  thread  and  passed  closed  through  the  nostril, 
and  when  the  end  has  reached  the  pharynx  the  spring  is  projected, 
coils  around  under  the  soft  palate,  and  appears  with  the  thread  in  the 
mouth.  The  thread  is  then  pulled  through  the  mouth,  thus  leavdng 
one  end  through  the  mouth,  the  other  through  the  nostril.  By  making 
traction  on  the  nose-end  of  the  thread  the  pledget  is  guided  by  the 
finger  in  the  mouth  into  the  posterior  nares.  The  loop  of  thread  is 
firmly  tied  to  an  anterior  loop,  which  is  forced  into  the  anterior  nares, 
and  the  other  end  is  allowed  to  hang  in  the  pharynx  or  outside  the 
mouth. 

Fracture  of  the  Malar  Bone. — The  most  common  position  for 
fracture  of  this  bone  is  at  the  zygoma,  and  it  is  always  caused  by  direct 
violence.  The  prominence  of  the  bone  and  the  sharp  outline  of  its 
orbital  margin  make  diagnosis  comparatively  easy.  As  a  rule,  this  bone 
is  fractured  in  some  serious  injuiy  which  involves  other  bones  of  the 
face  and  skull. 

Fracture  of  the  Upper  Jaw. — -The  whole  bone  may  be  driven 
in  by  direct  violence,  causing  extreme  deformity,  or  the  wall  of  the 
antrum  may  be  fractured,  or  the  fracture  may  run  along  above  the 
alveolar  margin,  so  that  the  teeth  are  movable  as  if  they  were  a  set 
of  false  teeth.  The  diagnosis  must  be  based  upon  the  deformity,  the 
nature  of  the  accident,  hemorrhage,  and  mobility  of  the  part.  A  guarded 
prognosis  should  be  given,  as  the  brain  or  bones  of  the  skull  may  be 
seriously  involved. 

Treatment. — It    frequently  happens  that    direct  pressure   with  the 


6o  SL-RG/CAL    DIAGNOSIS  AND    'J-REATMENT. 

fingers  is  sufficient  to  correct  the  displacement  and  no  retentive  appa- 
ratus is  necessary.  When  the  alveolar  border  is  the  seat  of  fracture 
and  the  fragment  is  movable,  it  may  be  necessary  to  maintain  the  parts 
in  proper  position  by  wiring  the  teeth  in  the  detached  bone  to  those 
which  arc  still   in  ])osition. 

Fracture  of  the  I/Ower  Jaw. — This  fracture  may  result  from  direct 
or  indirect  violence.  The  most  frequent  seat  of  injury  is  near  the  canine 
tooth  and  immediately  in  front  of  the  mental  foramen.  The  angle,  the 
symphysis,  the  neck  of  the  condyle,  and  the  coronoid  process  must  all 
be  examined.  When  the  fracture  is  compound  the  breach  of  the  soft 
parts  is  generally  in  the  mouth.  The  teeth  are  frequently  loosened  or 
completely  separated.  By  passing  the  fingers  over  the  surfaces  of  the 
bone  any  irregularity  can  be  felt,  and  in  most  cases  crepitus  can  be 
produced.  When  the  fracture  is  through  the  horizontal  ramus  one  of 
the  fragments  drops  to  a  slight  extent,  owing  partly  to  its  weight,  but 
chiefly  to  the  action  of  the  muscles  attached  to  the  hyoid  bone.  When 
the  bone  is  broken  at  its  neck  the  condyle  is  drawn  out  of  its  socket 
by  the  action  of  the  pterygoid,  while  the  rest  of  the  jaw  is  drawn 
toward  the  opposite  side  by  the  other  muscles. 

Pain  is  severe,  and  particularly  when  any  attempt  is  made  at  masti- 
cation. The  patient  finds  it  difficult  to  speak,  and  steadies  his  jaw 
with  one  hand. 

Trcatnioit. — In  simple  cases  the  parts  are  easily  kept  in  position.  A 
good  retentive  apparatus  is  the  following,  which  I  quote  from  Mansell 
Moullin :  "  One  webbing  strap  is  placed  beneath  the  jaw,  carried 
upward  on  either  side  over  the  temporal  region,  and  fastened  a  little  in 
front  of  the  vertex ;  and  a  second  is  placed  horizontally  around  the 
forehead  and  below  the  occipital  protuberance.  Where  they  cross  a 
slit  should  be  cut  in  the  horizontal  one  to  allow  the  other  to  pass 
through,  or  they  should  be  sewn  together,  and  for  additional  security 
they  may  be  connected  by  a  tape  over  the  sagittal  suture.  Buckles, 
protected  underneath  with  little  wash-leather  pads,  should  be  used  to 
secure  them.  In  ordinary  cases  there  is  no  tendency  to  displacement 
forward ;  but  if,  owing  to  the  convexity  of  the  lower  margin  of  the 
jaw,  the  vertical  band  is  inclined  to  slip  too  far  back,  it  may  be  secured 
in  position  by  a  tape  stitched  to  it  and  passed  in  front  of  the  chin." 
The  four-tailed  bandage  is  a  time-honored  appliance,  but  much  inferior 
to  the  above  method,  as  it  has  a  tendency  to  become  loose  and  untidy. 

A  splint  of  gutta-percha  moulded  to  the  part  is  an  excellent  method 
when,  owing  to  the  obliquity  of  the  fracture,  lateral  pressure  has  a 
tendency  to  displace  one  of  the  fragments  inward. 

Interdental  splints  of  various  kinds  have  been  invented,  and  excel- 
lent results  have  been  obtained  by  wiring  the  fragments,  either  through 
the  medium  of  the  teeth  or  by  drilling  holes  in  the  jaw  itself 

Fracture  of  the  Clavicle. — Of  all  fractures,  this  is  the  one  met 
with  most  frequently.  It  occurs  generally  as  the  result  of  indirect 
violence,  as  when  the  patient  falls  to  the  ground,  alighting  upon  his 
shoulder. 

The  most  common  position  of  the  fracture  is  in  the  middle  of  the 
bone  or  a  little  farther  toward  the  outer  end.  By  direct  violence  any 
part  of  the  bone  may  be  broken.     The  position  assumed  by  a  person 


INJURIES  AND  DISEASES   OF  THE    OSSEOUS  SYSTEM.  6l 

with  a  fractured  clavicle  is  so  characteristic  that  a  diagnosis  can  almost 
be  made  from  that  alone.  The  head  is  inclined  toward  the  injured 
clavicle,  and  the  free  hand  is  used  to  support  the  arm  on  the  injured 
side.  The  shoulder  slopes  more  than  in  health,  and  is  drawn  nearer 
the  middle  line  of  the  body.  A  projection  may  be  seen  over  the  clav- 
icle, and  if  not  seen  it  can  be  readily  felt  by  passing  the  fingers  along 
the  bone,  when  the  exquisite  pain  at  that  particular  point  and  the  pres- 
ence of  a  sharp  projection  leave  no  doubt  of  the  nature  of  the  injury. 
It  is  not  worth  while  looking  for  crepitus  and  increased  mobility,  as 
the  patient's  sufferings  are  greatly  aggravated  by  any  manipulations. 
The  only  exception  to  be  made  is  when  the  fracture  is  at  the  coraco- 
clavicular  ligament.  Here  the  symptoms  to  be  relied  upon  are  tender- 
ness and  slight  crepitus  when  moderate  pressure  is  made. 

In  children  the  fracture  is  often  incomplete,  the  so-called  grcoi-stick 
fracture. 

Displacement. — When  the  fracture  is  incomplete  there  is  a  simple 
elevation  about  the  middle  of  the  bone.  When  the  fracture  is  complete 
the  displacement  is  much  more  marked.  The  inner  fragment  remains 
undisturbed,  for  it  is  steadied  by  the  rhomboid  ligament  and  the  costo- 
coracoid  membrane  below  and  the  sterno-mastoid  muscle  above.  Some- 
times, however,  the  outer  end  of  this  fragment  is  drawn  upward  against 
the  skin,  which  it  may  even  perforate.  The  outward  fragment  is  the 
one  which  is  displaced — first,  downward  by  the  weight  of  the  arm ; 
second,  inward  by  the  action  of  the  pectoral  muscles ;  third,  forward 
by  the  action  of  the  serratus  magnus  and  pectorals,  which  rotate  its 
outer  end  until  it  forms  an  angle  with  the  true  axis  of  the  bone. 

TreatmeJit. — To  effect  reduction  the  shoulder  must  be  drawn  in  the 
direction  exactly  opposite  to  the  displacement — viz.  upward,  backtcard, 
and  outivard — and  the  parts  must  be  kept  in  this  position.  The  sim- 
plest appliance  for  this  purpose  is  Sayre's  dressing.  Take  two  strips 
of  adhesive  plaster  (spread  on  moleskin  ;  cotton  is  too  weak)  three 
inches  wide  and  of  sufficient  length  to  go  once  and  a  half  around  the 
chest.  Pass  the  end  of  one  strap  around  the  arm  of  the  affected  side 
just  below  the  axilla,  and  fasten  securely,  but  not  tight  enough  to  inter- 
fere with  the  venous  circulation.  Draw  the  shoulder  well  back  and 
carry  the  strap  around  the  chest,  so  as  to  hold  the  arm  with  the  elbow 
a  little  behind  the  axillary  line.  Now  place  the  forearm  of  the  injured 
side  across  the  chest,  so  that  the  fingers  point  to  the  opposite  shoulder. 
Carry  the  second  strip  from  the  uninjured  shoulder  across  the  back  to 
the  opposite  elbow,  and  up  along  the  forearm  to  the  place  of  begin- 
ning ;  at  the  same  time  the  elbow  must  be  pressed  forward,  inward,  and 
upward  (Fig.  i6).  Absorbent  cotton  or  other  suitable  material  should 
be  placed  between  the  forearm  and  chest,  lest  retained  moisture  cause 
irritation  and  perhaps  ulceration  of  the  skin.  The  parts  may  be  still 
further  supported  by  a  few  turns  of  a  bandage  about  the  arm  and  chest. 

Velpeau's  bandage  (Fig.  i/)  is  a  time-honored  method  of  treating 
fractured  clavicle,  but  has  no  advantage  over  Sayre's  dressing.  Should 
you  happen  to  be  so  situated  that  suitable  materials  are  not  at  hand,  a 
very  efficient  appliance  can  be  made  by  the  use  of  two  good-sized 
handkerchiefs  or  pieces  of  calico  about  one  foot  and  a  half  square. 
Fold  each  handkerchief  till  two  opposite  corners  meet,  then  fold  it  into 


62 


SCA'G/C.I/.    7^/AGXOS/S  AND    TREATMENT. 


a  band  about  four  inches  wide.  Around  each  shoulder  pass  a  hand- 
kerchief thus  folded,  and  tie  the  ends  in  a  single  knot  over  the  scapula. 
Now  draw  the  shoulders  well  backward,  and  retain  them  in  this  posi- 
tion by  tying  the  two  ends  of  the  right  handkerchief  to  the  two  ends 
of  the  left.  The  arm  is  next  flexed  across  the  chest,  and  a  sling  applied 
to  support  the  forearm  and  elbow.  When  Sayre's  and  Velpeau's 
methods  are  objectionable,  the  patient  may  be  placed  in  the  recumbent 
position  with  a  sand-bag  under  the  scapula  of  the  affected  side.  The 
shoulder  is  then  weighted  with  anything  that  will  steady  the  parts.  The 
fragments  naturally  coapt  themselves  in  this  position.  When  union  has 
partially  taken  place  suitable  bandages  are  applied  until  repair  is 
complete. 

Union  may  be  expected  in  about  four  weeks  in  adults,  but  it  is  well 
to  warn  patients  that  there  is  always  more  or  less  deformity  result- 
ing from  thickening  of  the  bone.     The  thickened  bone  may  even  make 


(■^ 


Fig.  i6. — Sayre's  adhesive-plaster  dressing  for 
fracture  of  the  clavicle  (Stimson). 


Fig.  17. — Velpeau's  bandage. 


pressure  upon  the  nerves  of  the  brachial  plexus,  as  occurred  in  two 
cases  which  came  under  my  notice.     This  result  is  uncommon. 

It  is  seldom  that  any  complications  attend  fracture  of  the  clavicle. 
But  it  is  possible,  particularly  in  fracture  caused  by  direct  violence,  to 
have  injur)^  to  the  vessels  and  nerves,  and  even  perforation  of  the  lung. 

Laceration  of  the  subclavian  vein  or  the  internal  jugular  is  a  serious 
accident,  and  unless  promptly  treated  is  attended  with  fatal  results. 

Fracture  of  the  Hyoid  Bone. — This  is  a  rare  fracture.  It  often 
occurs  in  hanging,  in  which  case  the  body  of  the  bone  is  broken,  or  by 
the  force  of  the  thumb  and  finger  when  the  throat  is  grasped  by  an 
assailant.  In  this  case  one  of  the  greater  cornuae  is  the  part  to  suffer, 
or  at  the  junction  of  the  body  with  the  cornua.  Blows  upon  the  throat 
and  even  muscular  contraction  have  been  observed  as  causes. 

Syiiiptoins. — The  victim  may  feel  a  sensation  as  if  a  bone  had 
broken  ;  severe  bleeding  may  take  place,  more  especially  if  a  fragment 
has  perforated  the  mucous  membrane.  There  is  difficulty  in  swallow- 
ing, dyspnea,  salivation,  and  inability  to  speak.  Severe  pain  may  be 
felt  in  moving  the  tongue,  and  in  some  cases  the  tongue  is  drawn  to 
one  side.     The  greatest  danger  is  in  death  from  edema  of  the  glottis. 


INJURIES  AND  DISEASES   OF  THE    OSSEOUS  SYSTEM.  63 

Treatment. — Pass  a  finger  into  the  throat  and  draw  the  base  of  the 
tongue  as  far  forward  as  possible,  while  with  the  other  hand  the 
depressed  bones  are  moulded  into  proper  position.  No  retentive 
apparatus  can  be  applied,  and  all  that  needs  to  be  done  is  to  keep  the 
parts  at  rest  for  a  few  days  by  not  using  the  voice  and  swallowing  no 
food.     Nourishment  can  be  administered  by  the  rectum. 

Fracture  of  the  Sternum. — Look  for  this  fracture  at  or  near  the 
junction  of  the  manubrium  and  the  body  of  the  bone.  It  has  been  pro- 
duced by  lifting  heavy  weights,  by  severe  straining  during  labor,  or  by 
excessive  bending  of  the  body.  It  is  usually  simple  and  transverse,  but 
may  be  multiple.  Two  cases  which  I  have  attended  were  produced  by 
direct  violence.  The  symptoms  are  not  usually  well  marked.  Dis- 
placement may  be  slight,  for  the  periosteum  on  the  inner  surface  of  the 
bone  is  usually  untorn.  When  the  body  of  the  sternum  is  fractured  it 
is  usually  in  its  upper  half 

Diagnosis  must  be  based  upon  the  history  of  the  injury,  localized 
pain,  and  displacement  felt  by  pressing  the  fingers  over  the  bone. 
Dyspnea  and  irregularity  of  the  heart  have  been  noted  as  symptoms. 
The  head  and  shoulders  are  bent  forward  to  relieve  the  pain. 

Treatment. — While  the  patient  makes  a  deep  inspiration  force  the 
bone  into  position  by  direct  pressure,  aided,  if  need  be,  by  extension  of 
the  trunk.  A  broad  band  of  adhesive  plaster  around  the  chest,  with  a 
pad  between  the  shoulders,  is  the  best  appliance  for  retention. 

Fracture  of  the  Ribs. — When  a  rib  is  fractured  it  breaks  com- 
pletely, green-stick  fracture  being  rare.  The  man  who  can  diagnose  frac- 
ture of  the  ribs  and  never  make  a  mistake  is  a  good  surgeon.  I  have 
seen  more  errors  made  in  this  fracture  than  in  any  other.  The  ribs  most 
liable  to  suffer  are  those  from  the  fifth  to  the  ninth.  The  first  of  these 
is  probably  broken  more  frequently  than  is  recognized ;  the  remain- 
ing upper  ribs  are  seldom  fractured,  and  the  false  ribs  perhaps  never, 
except  in  gunshot  wounds.  One  or  several  ribs  may  suffer,  and 
one  or  several  may  be  broken  at  two  points  each.  Do  not  expect  to 
see  any  deformity  unless  several  ribs  are  fractured  and  the  chest-wall, 
as  sailors  say,  "  stove  in."  External  violence  is  the  commonest 
cause,  and  it  may  act  in  one  of  two  ways :  directly,  as  happened  to  a 
patient  of  mine,  who,  while  riding  along  in  an  open  buggy,  received  a 
severe  blow  from  the  end  of  the  pole  of  a  carriage  which  was  following 
too  closely  behind ;  or  indirectly,  as  when  the  chest  is  compressed  and 
the  natural  curve  of  the  ribs  is  thus  forcibly  increased.  Muscular 
action  has  produced  fracture  in  fits  of  severe  coughing — a  rare  occur- 
rence. 

Diagnosis. — Our  suspicion  of  fracture  should  be  aroused  if  the 
patient  after  an  injury  to  the  chest  complains  of  pain  on  drawing  a 
deep  breath  or  on  coughing,  and  especially  when  pressure  is  made  on 
one  particular  spot  in  the  chest-wall.  Place  your  hand  upon  the  pain- 
ful spot  and  ask  him  to  take  a  deep  inspiration ;  when  fracture  exists 
a  sensation  of  crepitus  is  felt  by  the  hand,  and  the  patient  also  feels  the 
sensation  in  his  side.  With  the  point  of  the  fingers  find  the  tenderest 
spot  and  feel  for  any  irregularity  in  the  bone  at  that  place.  Next 
place  a  finger  on  the  suspected  rib  on  each  side  of  the  fracture,  and 
you   will    perhaps    find    that    mov^ement    communicated    to    one  frag- 


64  SURGICAL   DIAGNOSIS  AXD    TREATMENT. 

nicnt  is  not  transmitted  to  the  others.  Place  your  stethoscope  or 
ear  o\-er  the  suspected  spot,  and  crepitus  may  be  detected  on  deep 
breathing.  Expectoration  of  blood  is  a  common  symptom,  and  so  is 
cellular  emphysema.  As  a  rule,  emphysema,  when  it  occurs,  extends 
over  several  square  inches  of  the  surface,  but  a  few  cases  are  recorded 
in  which  it  spread  over  nearly  the  whole  body.  If  the  fracture  is  com- 
pound, we  often  find  the  intercostal  artery  wounded.  The  most  common 
seat  of  fracture  of  the  ribs  is  at  or  near  the  angle,  about  four  inches 
from  the  vertebral  column. 

A  contusion  may  closely  simulate  fracture,  for  it  will  produce  pain 
and  difficulty  of  breathing  which  is  diaphragmatic.  A  fracture  may 
show  nothing  more,  for  there  may  be  no  hemoptysis,  and  in  some  cases 
it  is  impossible  to  elicit  crepitus.  When  uncertain,  give  fracture  the 
benefit  of  the  doubt ;  immobilization  of  the  chest-wall  will  give  the 
greatest  comfort  in  contusion,  and  is  also  the  proper  treatment  for 
fracture. 

Treatment. — Take  a  band  of  adhesive  plaster  about  six  to  nine 
inches  broad  and  carry  it  around  the  chest,  overlapping  about  one- 
half.  If  this  is  not  convenient,  use  several  narrow  strips  of  plaster,  and 
get  complete  immobility  of  the  affected  portion  of  the  chest-wall  by 
apph'ing  strips  vertical!}'. 

Fracture  of  the  Scapula. — Great  force  is  necessary  to  break 
the  scapula,  for  behind  it  are  the  elastic  ribs  and  a  cushion  of 
muscular  tissue  over  which  it  readily  slides  when  subjected  to  a  blow. 
Swelling  occurs  speedily,  and  makes  the  diagnosis  more  difficult  than 
in  most  bones,  and  hence  errors  must  be  guarded  against. 

Seven  different  fractures  of  the  scapula  are  recognized — viz:  i.  The 
body ;  2.  The  inferior  angle ;  3.  The  superior  angle ;  4.  The  spine ; 
5.  The  acromion  process;  6.  The  coracoid  process;  7.  The  neck. 

The  Body. — Pass  the  fingers  along  the  posterior  border  of  the 
scapula,  at  the  same  time  placing  the  bone  in  such  positions  as  elevate 
its  margins  and  render  them  more  prominent.  If  fracture  exist,  there 
will  be  overlapping  of  the  fragments.  Grasp  the  lower  angle  and 
crepitus  may  be  found,  but  it  must  be  remembered  that  overlapping 
on  the  one  hand  and  wide  separation  on  the  other  will  prevent  our 
finding   crepitus. 

The  Inferior  Angle. — Lay  the  forearm  across  the  back,  and  the 
angle  is  thrown  out  so  that  the  fingers  can  be  easily  pushed  behind  it. 
If  the  angle  is  broken  off,  the  displacement  is  forward  and  upward  by 
the  action  of  the  attached  muscles. 

TJie  Superior  Angle. — Place  the  hand  of  the  injured  side  upon  the 
opposite  shoulder,  with  the  forearm  lying  across  the  chest.  This  throws 
the  superior  angle  into  prominence,  when  it  can  be  examined.  The 
symptoms  of  fracture  here  are  obscure,  as  there  is  little  displacement 
and  often  great  swelling.  The  treatment  consists  in  keeping  the  arm 
immobilized. 

The  Spine. — In  thin  persons  the  spine  of  the  scapula  can  be  readily 
felt,  particularly  when  the  injured  arm  is  placed  behind  the  back.  By 
direct  violence  the  spine  may  be  broken  off  throughout  its  entire 
length,  including  the  acromion  process,  or  a  portion  of  it  may  be 
broken  off,  leaving  the  acromion  process  attached  to  the  body.     The 


INJURIES  AND  DISEASES   OF  THE    OSSEOUS  SYSTEM.  65 

displacement  is  slight,  and  the  evidence  must  rest  upon  the  mobility  of 
the  fragment  detached.     The  treatment  is  immobilization. 

T/ie  Acromion  Process. — Fracture  of  this  portion  of  the  bone  is 
produced  by  direct  violence,  by  indirect  violence  as  when  the  humerus 
is  pushed  violently  upward,  and  possibly  by  muscular  action  in  violent 
contraction  of  the  deltoid.  Mobility,  when  it  exists,  is  the  most  import- 
ant symptom ;  there  may  also  be  crepitus,  and  there  is  always  tender- 
ness on  pressure.  An  error  in  diagnosis  is  apt  to  be  made  in  cases 
where  the  epiphysis  at  the  external  end  of  the  spine  has  failed  to  unite. 
This  condition,  combined  with  a  contusion,  might  readily  be  mistaken 
for  fracture.  Beginning  posteriorly,  run  the  fingers  along  the  spine 
toward  the  acromion  to  search  for  any  irregularity,  fissure,  or  depres- 
sion. The  acromion  may  next  be  grasped  to  test  its  mobility  and  to 
elicit  crepitus.  Three  separate  lines  of  fracture  are  to  be  recognized — 
viz.  in  front  of  the  clavicle,  through  the  articulation  with  the  clavicle, 
and  posterior  to  the  articulation.  In  the  first  of  these  the  clavicular 
attachment  is  not  interfered  with,  and  hence  the  position  of  the  arm  in 
its  relation  to  the  body  will  not  be  changed.  In  the  two  latter  forms 
the  clavicle  is  involved,  and  the  result  is  that  the  shoulder  assumes  the 
very  position  which  it  takes  in  fracture  of  the  clavicle — viz.  downward, 
forward,  and  inward.  Trcatvicnt. — Immobilize  the  arm  at  the  side  of 
the  body,  the  elbow  a  little  forward,  and  the  humerus  pressed  well 
upward  against  the  acromion. 

TJie  Coracoid  Process. — The  coracoid  process  can  be  felt  in  the  space 
between  the  anterior  border  of  the  deltoid  and  the  pectoralis  major. 
When  fractured  by  muscular  action,  as  sometimes  happens,  the  dis- 
placement is  downward  by  the  action  of  the  coraco-brachialis.  When 
not  detached,  the  finger  resting  upon  the  tip  of  the  process  can  detect 
mobility,  and  perhaps  crepitus.  The  treatment  is  immobilization  of  the 
arm  against  the  chest,  with  the  elbow  drawn  slightly  backward. 

The  Neck. — The  most  prominent  symptom  in  this  variety  of  fracture 
is  a  falling  down  or  flattening  of  the  shoulder.  The  humerus  sinks 
down,  owing  to  the  loss  of  support  from  the  triceps.  When  the  arm 
is  pressed  upward  this  deformity  disappears,  to  return  as  soon  as  the 
arm  is  left  unsupported.  Follow  the  axillary  border  of  the  scapula 
upward,  and  in  the  axilla  you  will  find  a  movable,  hard  lump.  By  an 
upward  and  backward  movement  crepitus  can  be  detected.  The  indi- 
cation for  treatment  is  to  prevent  sinking  of  the  humerus.  This  can  be 
accomplished  by  the  application  of  a  Velpeau  bandage  or  a  strip  of 
adhesive  plaster  passing  into  the  flexed  elbow  and  over  the  shoulder 
of  the  same  side. 

Fracture  of  the  Humerus. — Fracture  of  the  shaft  of  the 
humerus  is  very  easily  diagnosticated.  The  deformity  is  usually  well 
marked.  Pain  is  intense  and  helplessness  complete.  The  fragments 
can  be  felt  through  the  skin  and  crepitus  is  readily  detected.  The 
brachial  artery  is  rarely  injured,  but  the  musculo-spiral  nerve  not 
infrequently  suffers,  either  by  direct  injury  at  the  time  of  the  accident, 
or  at  a  later  period  it  may  be  compressed  in  the  callus.  In  children 
the  fracture  is  generally  transverse,  and  this  is  often  the  case  also  when 
due  to  muscular  exertion.  In  adults  the  common  direction  is  obliquely 
from  above  downward  and  outward.     When  the  fracture  is  above  the 


66 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


insertion  of  the  deltoid,  the  upper  fragment  is  drawn  inward  by  the 
muscles  of  the  chest ;  the  lower  fragment  is  drawn  outward  and 
upward  by  the  action  of  the  deltoid.  When  the  bone  is  broken  below 
the  insertion  of  the  deltoid,  the  relation  of  the  fragments  is  not  much 
disturbed,  for  the  muscles  antagonize  each  other. 

Probably,  of  all  bones  this  is  the  one  in  which  non-union  or  a  false 
joint  is  most  likely  to  occur.  The  reason  of  this  is  not  to  be  sought 
in  any  fault  of  the  bone  itself,  but  from  the  fact  that,  owing  to  the  great 
leverage  of  the  lower  fragment,  it  requires  the  utmost  care  to  keep  the 
parts  completely  immobilized.  Non-union  is  also  due  in  many  cases  to 
the  interposition  of  muscle  or  fascia  between  the  fragments. 

Treatment. — Bend  the  elbow  to  a  right  angle,  and  by  extension  in 
the  axis  of  the  bone,  aided  by  direct  manipulation,  replace  the  frag- 
ments. Sometimes  a  considerable  amount  of  traction  is  necessary  to 
effect  this,  and  in  the  case  of  compound  fractures  the  ends  of  the  frag- 
ments may  have  to  be  cut  off  A  good  retentive  apparatus  is  the 
shoulder-cap  splint,  long  enough  to  reach  the  elbow  and  enveloping 
two-thirds  of  the  circumference  of  the  arm  (Fig.  i8).     If  narrower  than 

this,  a  short  internal  splint  should 
be  used.  The  arm  is  to  be  carried 
in  a  sling  and  the  elbow  left  un- 
supported. A  weight  may  be  at- 
tached to  the  elbow  when  the 
patient  is  able  to  go  about,  and 
this  is  especially  indicated  when  he 
is  a  muscular  man.  Plaster  of 
Paris  is  an  excellent  dressing.  It 
need  not  be  made  so  bulky  as  to 
render  it  objectionable  from  its 
weight,  on  account  of  which  some 
writers  have  condemned  it. 

Fractures  of  the  upper  exd 
OF  THE  humerus  are  divided  into 
those  of  the  head,  of  the  anatomi- 
cal neck,  of  the  tuberosities,  sepa- 
tion  of  the  epiphysis,  and  fracture 
of  the  surgical  neck. 

1.  Fracture  of  the  head  cannot 
be  recognized  during  life. 

2.  Fracture  of  the  anatomical 
neck  is  a  rare  accident.     When  an 


Fig.  i8. — Apparatus  for   fracture    of   the    hu- 
merus at  any  point  above  the  condyles. 


anterior  dislocation  of  the  shoulder  takes  place,  it  is  possible  for  the 
anterior  lip  of  the  glenoid  cavity  to  act  as  a  wedge  against  which  the 
head  of  the  humerus  is  broken  off  The  same  thing  can  occur  when  a 
strong  force  applied  to  the  elbow  drives  the  humerus  upward  against 
the  scapula.     It  may  also  be  the  result  of  muscular  action. 

Diagnosis. — Grasp  the  tuberosities  of  the  humerus,  which  can  be 
felt  through  the  fibers  of  the  deltoid,  and  rotate  the  arm.  If  the 
tuberosities  move  with  the  shaft  and  crepitus  is  found,  the  fracture  is 
at  the  anatomical  neck.  When  dislocation  also  exists  the  head  can  be 
felt  to  move  independently  of  the  shaft. 


INJURIES  AND  DISEASES   OF  THE    OSSEOUS  SYSTEM.  6/ 

Trcatnioit. — The  action   of  the   deltoid  and  other  muscles  of  the 

■  shoulder  tends  to  draw  the  shaft  upward,  while  the  head  at  the  same 

time  slips  downward.    To  obviate  this,  the  proper  treatment  is  to  make 

traction  from  the  elbow  and  immobilize  the  arm.     In  most  cases  the 

shoulder-cap  with  a  folded  towel  in  the  axilla  is  a  good  appliance. 

3.  Fracture  through  the  tuberosities  is  usually  the  result  of  direct 
violence,  and  the  bone  is  often  comminuted  and  the  fracture  compli- 
cated with  extensive  injury  of  other  structures.  When  the  greater 
tuberosity  is  broken,  it  is  generally  as  a  complication  of  anterior  dis- 
location. It  is  recognized  by  the  want  of  voluntary  outward  rotation, 
by  crepitus,  pain,  and  swelling. 

4.  Separation  of  the  epiphysis  does  not  occur  in  persons  over 
twenty  years  of  age.  The  symptoms  are  the  same  as  those  of  the 
surgical  neck,  except  that  true  crepitus  is  wanting,  and  the  end  of  the 
bone,  when  it  is  possible  to  feel  it,  is  more  rounded  than  when  frac- 
tured. 

5.  Fracture  of  the  Surg-ical  Neck. — While  the  preceding  fractures 
of  the  humerus  are  rare,  this  one  is  quite  common.  It  is  produced  by 
direct  violence  or  by  a  fall  upon  the  elbow  or  hand.  Grasp  the  head 
of  the  humerus  with  the  thumb  and  fingers  of  one  hand  and  rotate  the 
elbow  with  the  other.  If  crepitus  and  increased  mobility  are  recog- 
nized, the  case  is  clear.  The  displacement  may  be  such  as  to  give  the 
appearance  of  dislocation  at  the  shoulder.  The  point  is  easily  settled 
by  means  of  Dugas's  test.  Place  the  hand  of  the  affected  side  on  the 
opposite  shoulder  and  bring  the  elbow  to  the  side  of  the  chest.  If  this 
can  be  done,  there  is  no  dislocation.  Another  method  is  by  Cal/azuays 
test.  Pass  a  tape  around  the  acromion  and  under  the  axilla;  if  there  is 
dislocation,  the  affected  side  will  measure  about  two  inches  more  than 
the  sound  one. 

Treatment. — Considerable  difficulty  may  be  found  not  only  in  re- 
ducing this  fracture,  but  in  keeping  it  in  proper  position.  Firm  traction 
must  be  made  until  the  lower  fragment  can  be  got  into  line  with  the 
upper.  A  wedge-shaped  pad  formed  of  a  towel  in  the  axilla,  with  a 
cup-shaped  shoulder-splint,  will  usually  prove  satisfactory.  If,  how- 
ever, displacement  recurs,  a  weight  must  be  attached  to  the  elbow. 
About  five  pounds  is  sufficient.  A  sling  supporting  the  wrist  is  needed 
in  all  cases. 

When  fracture  and  dislocation  both  exist  the  usual  practice  is  to 
attempt  to  reduce  the  dislocation,  under  an  anesthetic,  by  direct 
manipulation.  Failing  in  this,  two  other  courses  are  open :  either  to 
set  the  fracture  in  the  hope  of  reducing  the  dislocation  at  the  end  of 
four  or  five  weeks,  or  allowing  a  false  joint  to  take  place.  Both  of 
these  methods  are  unsatisfactor}^  A  method  which  promises  to  give 
much  better  results  is  one  employed  by  Dr.  McBurney  in  a  case 
reported  in  the  Annals  of  Surgery  for  April,  1894.  He  thus  describes 
it :  "  An  incision  should  be  made  through  the  soft  parts  down  to  the 
bone,  a  hole  drilled  in  the  bone,  a  stout  hook  inserted,  and  direct  trac- 
tion made  upon  the  upper  fragment  in  the  proper  position  "  (Fig.  19). 

Having  reduced  the  dislocation,  the  fracture  must  be  treated  in  the 
ordinary  way. 

When  impaction  is  found  to  exist,  no  attempt  should  be  made  to 


68  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

reduce  it,  for  it  will  ensure  bony  union.  In  cases  where  no  impaction 
takes  place  there  is  a  risk  that  nothing  better  than  fibrous  union  will 
be  obtained. 

Fractures  at  thp:  Lowkr  End  of  the  Humerus. — When  the 
elbow  is  bent  at  a  right  angle  three  bony  prominences  are  arrayed  in 
hne  at  the  back  of  the  joint.  These  are  the  internal  cond)'lc,  the 
olecranon  process  of  the  ulna,  and  the  external  condyle.  Any  disturb- 
ance of  this  relation  will  show  that  something  is  wrong. 

The  fractures  to  be  met  with  at  the  lower  end  of  the  humerus  are 
clinically  divided  into — (i)  those  that  are  external  to  the  joint,  and  (2) 
those  that  involve  the  joint. 

The  fractures  external  to  the  joint  are  three  in  number — viz.:  i. 
Transverse  fracture  above  the  olecranon  fossa ;  2.  Separation  of  the 
external  epicondyle ;  3.  Separation  of  the  epiphysis  of  the  same. 

The  fractures  which  involve  the  joint  are — 

1.  T-shaped  fracture ; 

2.  Separation  of  the  internal  condyle ; 

3.  Separation  of  the  external  condyle ; 

4.  Separation  of  the  lower  epiphysis. 

Transverse  fracture  above  the  condyles  is  produced  by  falls  upon 


Fig.  19. — Fracture-hook. 

the  elbow,  by  direct  violence,  or  by  overextension  of  the  elbow.  The 
direction  of  the  line  of  fracture  is  sometimes  transverse ;  at  other  times 
it  is  oblique  from  above  downward  and  forward.  At  first  sight  the 
deformity  resembles  that  of  dislocation  of  both  bones  backward.  But 
if  the  relation  of  the  bony  points  already  referred  to  is  found  to  be 
undisturbed,  there  cannot  be  dislocation.  Besides  this,  the  position  of 
the  deformity  is  farther  up  the  arm,  causing  an  apparent  shortening  of 
the  humerus.  The  elbow-joint  is  flexed  with  the  hand,  generally  in 
pronation.  In  front  there  is  a  prominence,  which  is  the  lower  end  of 
the  upper  fragment,  while  posteriorly  there  is  a  depression  above  the 
olecranon  which  is  bridged  over  by  the  tendon  of  the  triceps.  Add  to 
this  the  existence  of  shortening  of  the  humerus,  the  presence  of  pre- 
ternatural mobility,  and,  as  a  crucial  test,  crepitus,  and  no  doubt  can 
remain  as  to  the  existence  of  fracture. 

Treatment. — When  the  line  of  fracture  is  oblique  it  is  difficult  to 
prevent  shortening,  as  the  action  of  the  muscles  tends  to  cause  over- 
lapping of  the  fragments.  Both  diagnosis  and  treatment  are  often 
interfered  with  by  excessive  swelling,  which  must  be  got  rid  of  before 
the  application  of  a  permanent  dressing.     If  the  case  can  be  seen  and 


INJURIES  AND  DISEASES   OF  THE    OSSEOUS  SYSTEM.  69 

the  fracture  set  immediately  after  the  injury,  this  swelHng  will  be  pre- 
vented. If  seen  later,  the  swelling  can  be  reduced  by  cold  applications, 
followed  after  a  few  hours  by  gentle  compression.  For  this  purpose 
absorbent  cotton  and  a  bandage  are  the  best,  great  care  being  taken  to 
watch  the  fingers,  lest  circulation  in  the  arm  be  interfered  with.  The 
best  splint  is  strong  pasteboard,  cut  in  a  rectangular  form,  running 
from  the  axilla  to  the  wrist.  After  soaking  in  hot  water  this  can  be 
moulded  to  the  parts,  and  it  closely  adapts  itself  to  the  limb.  The 
splint  should  be  applied  along  the  posterior  aspect  of  the  arm  and  the 
under  surface  of  the  forearm.  A  short  anterior  splint  should  be  applied 
down  the  arm,  with  a  thick  padding  opposite  the  bend  of  the  elbow, 
with  a  view  to  prevent  forward  displacement  of  the  upper  fragment. 
The  arm  must  be  carried  in  a  sling. 

Passive  motion  should  be  employed  about  the  end  of  the  second 
week.  Great  care  must  be  taken  lest  the  newly-formed  callus  be 
broken  up  and  a  failure  of  union  result. 

Fracture  of  the  internal  epicondyle  may  be  a  complication  of  dis- 
location, or  may  occur  by  itself  as  a  result  of  direct  violence  or  by 
muscular  action.  The  diagnosis  is  often  obscured  by  swelling,  but  in 
many  cases  the  bone  may  be  grasped  by  the  thumb  and  finger  and 
crepitus  elicited.  When  external  to  the  capsule  of  the  joint,  as  the 
separation  of  this  process  of  bone  usually  is,  the  accident  is  not  of 
serious  moment.  Besides  crepitus,  the  other  symptoms  are  pain  on 
pronation  and  also  on  extreme  flexion  and  extension,  while  a  moderate 
degree  of  either  of  the  two  latter  movements  is  free  from  inconvenience. 

Treatment. — Carry  the  arm  in  a  sling  with  the  elbow  at  a  right 
angle. 

Fractures  into  the  Joint. —  i.  The  most  important  of  this  group  is 
a  transverse  fracture  of  the  lower  end  of  the  humerus,  with  a  vertical 
fracture  running  from  it  into  the  joint.  For  convenience'  sake  we 
speak  of  this  as  a  T-shaped  fracture.  The  cause  is  always  direct  vio- 
lence. The  lower  end  of  the  humerus  is  split  between  its  condyles  by 
a  wedge,  and  the  wedge  which  splits  it  is  the  olecranon  process  of  the 
ulna.  From  the  tip  of  this  process,  running  backward  along  the 
greater  sigmoid  cavity,  is  a  ridge  which,  when  driven  with  great  force 
against  the  humerus,  cleaves  the  bone  from  its  articular  surface  upward 
and  breaks  it  off  transversely,  producing  the  T-shaped  fracture. 

Diagnosis. — The  symptoms  are  very  similar  to  those  of  supra- 
condyloid  fracture,  of  which  this  may  be  regarded  as  an  aggravated 
form.  The  lower  end  of  the  humerus  being  split,  the  condyles  are 
spread  apart,  and  consequently  the  end  of  the  humerus  appears  to  be 
wider  than  normal.  The  radius  and  ulna  are  displaced  upward  and 
backward,  but  the  three  bony  points  are  still  in  line,  so  we  have  no 
dislocation.  The  humerus  is  shortened  and  there  is  increased  mobility. 
Crepitus  can  be  detected  in  two  places — at  the  transverse  fracture  and 
also  when  one  condyle  is  rubbed  against  the  other. 

This  is  one  of  the  most  difficult  of  fractures  to  deal  with.  So 
rapidly  does  swelling  come  on  that  it  interferes  with  the  diagnosis. 
Reduction  may  be  by  no  means  easy,  while  union  without  more  or  less 
stiffness  in  the  joint  is  rare.  The  patient  and  his  friends  should  be 
explicitly  warned  on  all  these  points  the  moment  the  nature  of  the 


70  SURGICAL  DIAGNOSIS  AND    TREATMENT. 

injury  is  made  out.  Violent  inflammation  in  the  joint  and  around  it 
may  be  looked  for,  and  deformity  with  bony  ankylosis  is  exceedingly 
common  in  spite  of  the  most  careful  attention. 

Treatment. — So  unfavorable  has  been  the  prognosis  in  this  fracture 
that  surgeons  have  been  in  the  habit  of  putting  the  arm  in  the  position 
which  would  give  the  least  embarrassment  should  bony  ankylosis 
result.  That  position  is  at  a  right  angle  or  a  little  more.  The  first  part 
of  the  treatment  will  probably  consist  in  dealing  with  a  greatly  swollen 
and  inflamed  joint,  more  particularly  if  the  injury  is  not  seen  almost 
immediately  after  its  occurrence.  Reduction  must,  if  possible,  be 
effected  at  once.  Extension  and  counter-extension  will  disengage  the 
olecranon  (the  wedge  which  has  split  the  humerus),  and  the  condyles 
which  have  been  spread  apart  can  then  be  pressed  back  into  position. 
The  fragments  must  be  brought  into  line  with  the  shaft  of  the  humerus, 
and  moulded,  as  it  were,  by  direct  manipulation.  For  the  first  week 
this  will  need  frequent  attention,  so  that  a  faulty  position  can  be  recti- 
fied. At  the  end  of  the  second  week  the  callus  will  have  become  so 
firm  that  no  further  readjustment  can  be  made.  It  has  been  the  com- 
mon practice  to  put  this  fracture  up  in  exactly  the  same  kind  of  splint 
as  that  recommended  for  fracture  above  the  condyles. 

Within  the  last  few  years  the  treatment  of  fractures  in  the  neigh- 
borhood of  the  elbow-joint  has  received  considerable  attention.  The 
method  of  setting  the  fracture  with  the  arm  in  the  extended  position 
has  been  strongly  recommended,  and  several  cases  have  been  recorded 
to  demonstrate  the  superiority  of  this  plan.  Unfortunately,  the  matter 
has  not  been  satisfactorily  disposed  of,  for  the  success  of  the  extended 
position  is  by  no  means  uniform.  Dr.  James  S.  Wight  in  the  Ajinals 
of  Surgery  for  August,  1893,  reports  10  cases  treated  in  this  manner,  in 
all  of  which  bony  ankylosis  followed;  5  of  these  joints  had  to  be 
resected,  and  4  others  were  treated  by  brisement  force. 

If  the  advocates  of  the  straight  position  could  show  that  uniformly 
good  results  were  obtained  by  this  method,  it  would  be  wrong  not  to 
adopt  it,  but  that  evidence  is  wanting.  In  the  mean  time,  the  safer 
course  is  to  put  the  arm  up  in  that  position  in  which,  should  ankylosis 
take  place,  the  limb  will  be  most  useful.  Midway  between  flexion  and 
extension,  in  the  main,  gives  the  best  results.  I  have  had  3  cases  so 
treated  in  which  the  usefulness  of  the  limb  is  perfectly  restored  and  the 
deformity  insignificant 

fracture  of  the  Internal  or  External  Condyle. — Owing  to  its 
prominence  the  internal  condyle  is  broken  more  frequently  than  the 
external.  When  a  person  falls  backward,  as  upon  an  icy  sidewalk,  it  is 
the  internal  condyle  that  is  likely  to  be  the  first  to  come  in  contact  with 
the  ground.  The  fracture  is  apt  to  run  into  the  trochlear  surface  of 
the  joint.  The  external  is  rarely  fractured :  it  may  be  the  result  of 
direct  violence  or  of  a  fall  upon  the  hand. 

The  symptovis  are  very  similar  to  those  found  in  the  T-shaped  frac- 
ture, but  not  nearly  so  severe.  In  the  case  of  the  internal  condyle  the 
fragment  is  displaced  upward  and  backward.  This  throws  the  exter- 
nal condyle  into  undue  prominence.  By  grasping  the  condyle  between 
the  thumb  and  fingers  crepitus  can  be  discovered.  When  placed  in 
position,  contraction  of  the  triceps  tends  to  renew  the  displacement. 


INJURIES  AND  DISEASES  OF  THE    OSSEOUS  SYSTEM.  J I 

The  same  result  follows  pressure  upon  the  ulna  near  the  elbow.  For 
this  reason  the  arm,  when  carried  in  a  sling,  should  be  supported  only 
at  the  wrist. 

Treatment. — Carefully  replace  the  fragment,  and  apply  a  rectangular 
moulded  splint  along  the  back  of  the  arm  and  forward  to  the  wrist. 
The  forearm  rests  upon  the  splint  with  the  palm  downward,  in  order  to 
relax  the  flexors  and  the  pronator  radii  teres. 

The  complications  of  this  fracture  are  dislocation  of  the  radius  back- 
ward and  the  formation  of  exuberant  callus,  which  may  impair  the 
movement  of  the  elbow  after  union  has  taken  place.  Fracture  of  the 
external  condyle  is  treated  by  immobilization  in  a  posterior  rectangular 
splint  or  a  plaster-of-Paris  cast. 

Separation  of  the  Epiphysis. — At  the  lower  end  of  the  humerus  are 
four  centers  of  ossification — viz.  one  at  the  radial  portion  of  the  articu- 
lar surface,  which  appears  about  the  end  of  the  second  year  and  extends 
inward  to  form  the  chief  part  of  the  articular  end  of  the  bone ;  one  to 
form  the  inner  part  of  the  articular  surface,  appearing  about  the  twelfth 
year ;  one  for  the  internal  condyle,  appearing  about  the  fifth  year ;  one 
for  the  external  condyle,  appearing  about  the  thirteenth  or  fourteenth 
year.  The  outer  condyle  and  both  portions  of  the  articulating  surface 
unite  with  the  shaft  at  the  age  of  sixteen  or  seventeen  years.  The 
inner  condyle  becomes  joined  at  about  the  age  of  eighteen. 

In  infants  a  common  accident  is  to  have  the  whole  of  the  car- 
tilaginous mass  at  the  lower  end  of  the  humerus  separated  from  the 
shaft.  The  same  may  occur  in  children,  and  the  joint  may  or  may  not 
be  involved.  The  most  common  cause  is  excessive  adduction  or  abduc- 
tion of  the  forearm  with  hyperextension. 

The  treatment  is  the  same  as  for  supracondyloid  fracture. 

Fracture  of  the  Ulna. — The  olecranon  may  be  fractured  by  a 
blow  or  a  fall  upon  the  elbow,  or  it  may  be  wrenched  off  by  forcible 
contraction  of  the  triceps  muscle.  If  the  periosteum  remains  intact, 
the  displacement  is  slight,  but  otherwise  the  fragment  may  be  drawn 
upward  by  the  triceps  to  the  extent  of  two  inches  or  more. 

Syjnptoms. — Diagnosis  of  this  fracture  is  generally  attended  with 
little  difficulty.  The  nature  of  the  accident  and  intense  pain  over  the 
point  of  the  elbow  are  very  suggestive.  If  there  is  no  displacement, 
crepitus  can  generally  be  felt ;  if  the  fragment  is  drawn  upward,  its 
absence  from  the  normal  and  presence  in  the  new  position  leave  us  no 
longer  in  doubt. 

Treatment. — When  the  periosteum  is  intact  and  the  fragment  remains 
in  contact  with  the  ulna,  no  other  treatment  is  necessary  than  a  sling, 
with  immobilization  of  the  arm  or  a  plaster-of-Paris  cast.  In  most 
cases,  however,  the  displacement  will  be  considerable,  and  this  treat- 
ment will  not  suffice.  The  elbow  must  be  placed  in  almost  full  exten- 
sion, immobilized,  and  the  fragment  drawn  down  to  its  proper  position. 
The  simplest  way  of  doing  this  is  by  means  of  a  piece  of  adhesive 
plaster  cut  in  the  form  of  the  letter  U.  The  curve  is  placed  on  the 
back  of  the  arm  just  above  the  fracture,  and  the  sides  are  drawn  down 
and  applied  to  the  sides  of  the  forearm.  Cutting  down  upon  the  frag- 
ment and  wiring  it  to  the  olecranon  has  been  practised,  but  the  cases 
in  which  this  should  be  resorted  to  are  rare. 


yi  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

Fracture  of  the  coronoid  process  is  rare.  It  occurs,  as  a  rult-, 
when  there  is  backward  dislocation  of  both  bones.  A  fall  upon  the 
hand  when  the  elbow  is  extended  will  also  produce  it,  and  of  course 
it  can  be  produced  by  direct  violence.  Muscular  action  does  not  cause 
it,  for  the  only  muscle  that  is  attached  to  it  is  the  brachialis  anticus, 
and  this  is  also  attached  to  a  considerable  portion  of  the  shaft  of  the 
ulna.  For  this  reason  there  is  little  displacement  when  the  process 
is  broken  off. 

Syjiiptovis. — Extend  the  elbow-joint  and  the  bones  of  the  forearm 
become  displaced  backward.  Traction  upon  the  arm  brings  the  bones 
to  their  proper  place,  but  the  moment  this  force  is  relaxed  the  bones 
return  to  their  abnormal  position.  Swelling  exists  to  a  considerable 
degree.     There  is  intense  pain  on  pressure  and  also  on  flexion. 

Treatment. — Flex  the  joint  to  a  little  less  than  a  right  angle  and 
immobilize  with  plaster  of  Paris  or  splints.  Passive  motion  should  be 
gently  begun  at  the  end  of  a  week.     Union  is  generally  ligamentous. 

Fracture  of  the  Shaft  of  the  Ulna. — The  ulna  is  weaker  below  the 
middle  than  in  its  upper  portion,  and,  as  a  consequence,  fracture  is  most 
common  in  the  middle  or  lower  third.  From  its  exposed  and  subcuta- 
neous position  the  bone  is  most  frequently  broken  by  direct  violence 
and  the  fracture  is  often  compound.  When  the  radius  remains  unbroken 
the  displacement  in  fracture  of  the  ulna  is  not  very  marked.  The  arm 
is  comparatively  helpless  and  movement  is  painful. 

Treatment. — A  plaster-of-Paris  cast  or  a  moulded  pasteboard  or 
gutta-percha  splint,  grasping  the  whole  of  the  forearm  and  the  ulnar 
side  of  the  hand,  is  sufficient  in  ordinary  cases.  When  the  displace- 
ment is  angular  and  the  fragments  approach  the  radius,  the  treatment 
must  be  the  same  as  when  both  bones  of  the  forearm  are  broken.  A 
practical  point  worth  bearing  in  mind  is  that  when  the  forearm  is  car- 
ried in  a  sling  the  pressure  falls  upon  the  ulna  and  tends  to  displace  the 
fragments  toward  the  radius.  When  firm  splints  or  a  plaster  cast  are 
employed  the  ulna  is  guarded  against  this  danger. 

Fracture  of  the  Radius  and  Ulna  Together. — This  fracture 
is  readily  recognized.  It  occurs  mostly  in  the  lower  and  middle  thirds 
of  each  bone.  The  radius  is,  as  a  rule,  broken  higher  up  than  the 
ulna.  The  common  cause  is  a  fall  upon  the  hand.  Muscular  action  is 
very  rarely  a  cause. 

In  children  a  partial  or  green-stick  fracture  occurs  more  frequently 
here  than  in  any  other  bone. 

The  symptoms  are  pain,  swelling,  helplessness,  mobility,  and  crepitus. 

Treatment. — In  green-stick  fracture  the  child  should  be  placed  under 
an  anesthetic  if  necessary,  and  the  bone  straightened.  When  the  frac- 
ture is  complete,  traction  is  employed  and  the  fragments  adjusted  by 
direct  manipulation.  When  the  fracture  is  in  the  upper  third  of  the 
radius  and  above  the  insertion  of  the  pronator  radii  teres,  the  biceps 
supinates  the  upper  fragment.  This  must  be  corrected  by  putting  up 
the  forearm  in  the  supine  position ;  otherwise  the  power  of  supination 
in  the  limb  will  be  lost.  Another  mishap  to  be  avoided  is  the  tendency 
of  the  bones  to  approach  each  other.  When  the  reduction  has  been 
effected  deep  pressure  should  be  made  by  the  fingers  before  and  behind 
to  ensure  separation  of  the  bones.     The  best  retentive  apparatus  is  an 


INJURIES  AND  DISEASES   OF  THE    OSSEOUS  SYSTEM.  "JT, 

anterior  and  posterior  splint  a  little  wider  than  the  diameter  of  the  arm, 
and  carefully  padded  down  the  center  to  keep  the  bones  apart.  The 
splints  are  made  wide,  so  that  when  the  bandage  is  applied  it  exerts  no 
lateral  pressure.  The  forearm  must  be  carried  midway  between  pro- 
nation and  supination.  A  notable  and  expensive  lawsuit  occurred  a 
few  years  ago  for  the  alleged  reason  that  the  doctors  neglected  the 
maxim  "  thumbs  up." 

For  the  first  week  the  limb  should  be  frequently  examined,  and  the 
bones  separated  should  they  show  a  tendency  to  approximate.  At  the 
end  of  the  second  week  a  light  plaster-of-Paris  cast  can  be  applied. 
Passive  motion  (pronation  and  supination)  should  be  commenced  about 
the  end  of  the  third  week.  In  this  fracture,  as  well  as  in  all  other 
conditions  requiring  immobilization  of  the  forearm,  care  must  be  taken 
to  apply  the  bandage  while  the  elbow  is  flexed.  If  applied  in  the  ex- 
tended position  and  the  limb  be  afterward  flexed,  the  bandage  is  thereby 
tightened  and  there  is  a  danger  of  gangrene.  Another  risk  run  in  this 
accident  is  that  the  radial  and  ulnar  arteries  are  readily  compressed  by 
the  displacement  of  fragments  of  bone. 

Fracture  of  the  Radius  Alone. — The  head  of  the  radius  is 
fractured  mainly  as  a  complication  of  dislocation  of  the  elbow.  Frac- 
ture of  the  neck  has  been  observed  in  a  few  cases.  The  injury  is  de- 
tected by  the  examiner  placing  his  fingers  on  the  head  of  the  radius 
and  rotating  the  forearm,  when  it  will  be  found  that  the  head  does  not 
move  with  the  rest  of  the  bone.  Additional  evidence  of  the  fracture  is 
gained  when  pronation  and  supination  are  lost  and  when  pain  is  felt  at 
the  seat  of  the  injury  by  movement  of  the  hand  in  either  direction. 

Trcatmoit. — A  rectangular  splint  with  a  firm  pad  over  the  front  of 
the  forearm ;  passive  motion  about  the  third  week. 

Fracture  of  the  Shaft  of  the  Radius  Alone. — The  pronator 
radii  teres  is  inserted  into  the  rough  ridge  in  the  middle  of  the  outer 
surface  of  the  bone,  and  plays  an  important  part  in  fracture  of  the 
shaft.  When  fracture  takes  place  above  the  insertion  of  this  muscle 
the  upper  fragment  is  displaced  by  the  supinator  brevis  and  the  biceps, 
and  the  lower  fragment  by  the  pronators  ;  consequently,  the  relative 
position  of  the  radius  and  ulna  is  not  the  same  above  and  below  the 
seat  of  injury.  When  the  bone  is  broken  below  the  line  of  the  inser- 
tion of  the  muscle,  the  upper  fragment  is  but  slightly,  if  at  all,  dis- 
placed, the  pronator  radii  teres  holding  it  in  position ;  the  lower  frag- 
ment, however,  is  tilted  inward  toward  the  ulna  through  the  action  of 
the  supinator  longus  and  the  pronator  quadratus. 

Symptoms. — There  is  but  slight  displacement  so  long  as  the  ulna 
remains  intact.  Other  convincing  signs,  however,  are  not  wanting. 
There  is  pain  over  the  seat  of  the  injuiy.  Grasp  the  forearm  just  above 
the  wrist  and  rotate,  and  you  will  find  that  the  upper  part  of  the  radius 
does  not  move  with  the  rest  of  the  bone.  Crepitus  can  be  felt  and 
pronation  and  supination  are  lost. 

Treatment. — When  the  fracture  is  above  the  insertion  of  the  pro- 
nator radii  teres,  the  arm  should  be  put  up  in  a  position  of  complete 
supination.  The  upper  fragment  is  in  this  position  already,  and  we 
cannot  change  it ;  so  we  put  the  lower  fragment  in  the  same  form,  thus 
bringing  them  into  line.     This  is  all  very  well  in  theory,  but  the  posi- 


74  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

tion  is  a  trying  one,  and  patients  can  seldom  be  induced  to  submit  to  it. 
Lying  in  bed  with  the  arm  fully  extended  and  the  palm  upward  will 
serve  the  purpose.  Or  a  rectangular  splint  may  be  applied  to  the  pos- 
terior aspect  of  the  arm  and  forearm,  the  limb  being  carried  in  a  sling 
with  the  elbow  drawn  back,  so  that  the  middle  of  the  forearm  is  at  the 
lateral  middle  line  of  the  body. 

When  the  fracture  is  below  the  insertion  of  the  pronator  radii  teres 
the  indication  for  treatment  is  to  prevent  the  upper  end  of  the  lower 
fragment  from  being  drawn  inward.  This  might  result  in  union  with 
the  ulna,  and  as  a  consequence  the  loss  of  power  to  pronate  or  supi- 
nate.  Straight,  flat  splints  wider  than  the  diameter  of  the  arm  are  to  be 
applied  back  and  front,  with  carefully  formed  interosseous  pads,  and 
the  arm  carried  in  a  sling  "  thumb  up."  The  hand  should  be  un- 
supported. 

Fracture  of  the  Lower  End  of  the  Radius,  or  Colles's  Frac- 
ture.— With  the  single  e.xception  of  the  clavicle,  this  is  the  most 
common  of  all  fractures.     A  person  thrown  from  a  carriage  or  running 


Fig.  20. — "  Silver-fork  "  deformity  of  Colles's  fracture,  photographed  half  an  hour  after  the 

accident  (Keen  and  Wliite). 

and  falling  forward  instinctively  puts  out  his  hands  to  save  himself 
The  weight  of  the  body  thus  comes  upon  the  wrists.  A  tremendous 
strain  is  thrown  upon  the  joint ;  something  has  to  give  way,  and  it  must 
be  either  ligament  or  bone.  Clinical  evidence  has  shown  that  when  it 
comes  to  a  contest  between  ligament  and  bone,  the  bone  must  yield. 
In  this  case  the  radius  is  the  bone  to  suffer,  and  it  breaks  about  one 
inch  from  its  low^er  extremity.  The  accident  occurs  at  all  ages,  but  is 
more  common  in  advanced  life. 

The  direction  of  the  fracture  is  usually  transverse,  and  it  is  generally 
impacted.  It  may  be  oblique,  and  the  obliquity  may  be  in  either 
direction.  The  displacement  most  generally  met  with  is  that  of  the 
lower  fragment  driven  backward. 

Examination. — The  accident  happened  by  a  fall  forward  or  from  a 
height  upon  the  hand,  which  received  the  weight  of  the  body.  When 
the  force  came  upon  the  bone  the  forearm  was  nearer  a  vertical  than  a 
horizontal  position.  The  patient  carefully  nurses  the  wrist  on  the  palm 
of  the  other  hand.  Pain  is  felt  at  the  lower  end  of  the  radius.  The 
wrist   and   hand   are   helpless.     A  marked   and   peculiar   deformity  is 


INJURIES  AND  DISEASES   OF  THE    OSSEOUS  SYSTEM.  75 

apparent,  which  resembles  a  "  silver  fork"  (Fig.  20),  and  is  so  called. 
Look  at  the  dorsum  of  the  forearm  and  wrist.  The  back  of  the  hand 
appears  strangely  long.  Just  above  the  carpus  is  a  prominence.  This 
is  the  lower  fragment  driven  backward.  Immediately  above  it  is  a 
depression,  because  the  lower  fragment  is  not  in  line  with  the  upper. 
Next  examine  the  palmar  surface.  Just  above  the  carpus  is  a  depres- 
sion where  the  lower  end  of  the  radius  would  be  if  it  had  not  been 
driven  backward.  Immediately  above  this  is  a  prominence  which  is  the 
lower  end  of  the  upper  fragment.  Stand  at  the  patient's  elbow  and 
look  toward  the  hand,  and  the  appearance  is  very  remarkable.  The 
hand  is  drawn  toward  the  radial  side,  for  impaction  and  displacement 
have  shortened  the  radius.  The  ulna  looks  as  if  it  were  about  to  come 
through  the  skin.  The  fingers  are  flexed.  Pronation  and  supination 
are  impossible.  To  find  the  line  of  separation  make  firm  pressure 
along  the  outer  border  of  the  radius.  It  will  be  found  from  one-third 
to  three-fourths  of  an  inch  above  the  articular  edge. 

Errors. — Do  not  mistake  this  for  a  severe  sprain.  A  sprain  cannot 
show  the  same  deformity.  The  patient  may  think  he  has  a  dislocation 
of  the  wrist.  A  dislocation  of  the  wrist  is  a  very  rare  accident,  and 
cannot  be  confounded  with  this  fracture  except  by  the  careless  or 
uninformed. 

Treatment. — Reduction  is  difficult,  owing  to  the  impaction,  which 
must,  in  all  cases,  be  relieved.  Grasp  the  patient's  hand  with  yours  as 
in  the  act  of  handshaking,  make  strong  traction,  and  bend  the  wrist  at 
the  same  time  toward  the  ulnar  side.  If  this  fail,  place  the  wrist  in 
forced  extension,  and,  while  the  hand  is  drawn  upon,  push  the  fragment 
into  place  by  direct  manipulation.  It  is  of  the  utmost  importance  to 
the  after-appearance  of  the  limb  that  the  posterior  displacement  should 
be  fully  corrected. 

When  once  the  fracture  is  reduced  there  is  no  danger  of  its  being 
again  displaced,  and  on  this  account  the  matter  of  splints  is  of  minor 
importance.  When  preferred,  the  posterior  splint  may  end  at  the 
wrist :  the  anterior  one  may  end  at  the  same  level,  or  may  be  carried 
to  the  palm  with  a  pad  at  its  lower  end,  over  which  the  fingers  may 
rest  or  grasp.  A  plaster-of-Paris  dressing  is  often  employed,  but 
excellent  results  are  obtained  by  using  no  splints  at  all.  A  band  of 
adhesive  plaster  about  the  wrist  gives  support  and  allows  motion  of  the 
fingers  from  first  to  last,  which  is  a  very  important  point. 

When  the  anterior  or  posterior  lip  of  the  radius  is  broken  off  it  is 
known  as  Barton's  fracture. 

Fracture  of  the  Metacarpal  Bones. — These  bones  are  broken 
by  direct  violence,  as  in  fistic  encounters.  The  displacement  is  slight, 
and  crepitus  may  be  wanting.  The  diagnosis  is  made  by  pain  on 
pressure  and  by  pressing  the  corresponding  finger  upward. 

Treatment. — A  palmar  splint,  well  padded,  to  correspond  with  the 
natural  concavity  of  the  metatarsal  bones. 

Fractures  of  the  phalanges  are  usually  compound  and  the 
result  of  direct  violence.  The  diagnosis  is  easy,  as  the  usual  signs  of 
fracture  are  present.  The  treatment  consists  of  the  application  of  small 
palmar  splints  well  padded. 

Fracture  of  the   Pelvis. — Serious  injuries   are   often   met  with 


yd  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

about  the  pelvis.     They  may  be  caused  by  a  loaded  wagon  running 
over  that  part,  or  by  the  fall   of  heavy  bodies,  such  as  timber,  rock, 
or  earth,  or  by  the  pelvis  being  crushed  while  in  the  act  of  coupling 
railway  cars,  or  by  the  kick  of  a  horse.     It  is  puzzling,  even  to  the 
most  experienced,  to  discover  exactly  the  extent  to  which  the  parts 
have  suffered.     In  all  cases  of  this  kind  there  are  contusion  and  pain. 
Fright  often  plays  a  prominent  part,  for  the  terrible  sensation  of  feeling 
that  he  is  about  to  be  crushed  to  death  is  sufficient  to  put  an  ordinary 
person  into  a  condition  approaching  collapse.     The  pelvis  is  strong, 
and  so  constructed  that  it  can  resist  a  great  force  or  bear  an  enormous 
weight,  but  it  has  its  weak  points.     The  injuries  for  which  we  must  be 
on  the  lookout  in  accidents  occurring  in  the  manner  described  are — 
P'ractures  of  the  pelvic  bones ; 
Separation  of  the  symphysis  pubis ; 
Rupture  of  the  urethra  ; 
Rupture  of  the  bladder ; 
Injuries  of  the  abdominal  viscera. 

The  Pubic  Bone. — A  crushing  force  may  fracture  this  bone.  The 
line  of  fracture  runs  through  the  upper  ramus,  just  inside  the  ilio- 
pectineal  eminence,  and  through  the  lower  ramus  near  its  junction 
with  the  ischium.  Besides  giving  way  in  front,  the  pelvis  may  give 
way  posteriorly,  either  in  the  ilium  behind  the  acetabulum  or  in  the 
sacrum,  or  partly  in  either  bone  and  partly  in  the  sacro-iliac  synchon- 
drosis. Instead  of  fracturing  the  bone,  the  force  may  cause  separation 
of  either  the  pubic  or  sacro-iliac  symphysis,  or  both.  From  a  clinical 
standpoint  this  is  equivalent  to  a  fracture. 

Symptoms. — The  displacement  is  sometimes  very  marked,  not  only 
to  the  touch,  but  to  the  eye.  In  the  absence  of  this  evidence  we  rely 
upon  pain  under  direct  pressure  or  when  movement  is  made  by  grasp- 
ing the  wing  of  the  ilium.  If  blood  escapes  from  the  meatus,  we  know 
the  urethra  has  been  injured.  A  catheter  may  be  passed,  and  if  no 
urine  escapes,  then  the  bladder  is  ruptured.  This,  however,  may  be  the 
case  where  there  is  no  pelvic  fracture :  the  same  accident  may  happen 
from  a  kick  on  the  abdomen,  especially  when  urine  has  not  been  voided 
for  some  time  before  the  injury  is  inflicted.  The  patient  is  unable  to 
raise  the  leg  from  the  bed. 

Treatment. — Immobilize  the  pelvis  by  a  firm,  broad  girdle  or  plaster- 
of-Paris  cast.  When  double  vertical  fracture  exists,  employ  Buck's 
extension  upon  the  limb  as  in  fracture  of  the  femur.  If  the  fracture  is 
compound,  see  that  drainage  is  perfect  and  asepsis  maintained.  Rupture 
of  the  urethra  will  probably  require  perineal  section. 

The  Sacrum. — Fracture  of  this  bone  is  rare.  The  direction  is 
usually  transverse,  and  it  is  always  the  result  of  direct  violence. 
Common  complications  of  the  injury  are  paralysis  of  the  rectum,  the 
bladder,  and  the  lower  limbs.  The  displacement  is  angular,  and  cor- 
rection is  made  by  pressing  the  coccyx  forward.  The  coccyx,  when 
fractured,  presents  the  same  symptoms  as  dislocation  of  the  bone,  and 
requires  the  same  treatment  This  injury  is  almost  invariably  fatal,  as 
the  sacral  plexus  of  nerves  is  involved. 

The  Coccyx. — Fracture  of  this  bone  is  more  often  met  with  than 
the  last  named,  the  result  of  falls,  kicks,  or  gunshot  wounds.     Neur- 


INJURIES  AND  DISEASES   OE  THE    OSSEOUS  SYSTEM. 


77 


algia  of  the  coccygeal  nerves  is  often  present,  due  to  pressure  upon 
them.     The  pain  is  continuous,  and  is  called  coccydinia. 

Treatment. — The  same  as  that  for  fracture  of  the  pelvis.  The  addi- 
tion of  a  V-shaped  strip  of  adhesive  plaster  to  hold  the  bone  steady 
may  often  be  found  beneficial  in  relieving  the  pain. 

The  Ischium. — A  fall  upon  the  buttock  may  fracture  the  tuber- 
osities or  the  entire  bone. 

The  Ilium. — A  crushing  force  may  break  off  the  crest  of  the  ilium. 
Muscular  action  or  direct  violence  may  fracture  the  anterior  superior 
spinous  process.  The  posterior  inferior  and  the  posterior  superior 
spinous  processes  may  be  broken  by  direct  violence.  The  fracture  is 
recognized  by  the  presence  of  a  movable  fragment  with  crepitus. 

Treatment. — In  all  these  injuries  the  pelvis  must  be  immobilized  and 
the  patient  kept  quiet  in  bed.  Complications  must  be  treated  on 
general   principles. 

Fractures  of  the  Femur. — The  Neck  of  the  Femur. — When 


Fig,  21. — Fracture  of  the  small  part  of  the 
neck  of  the  femur  (Stimson). 


Fig.  22. — Fracture  at  the  base  of  the 
neck  of  the  femur,  with  spHtting  of  the 
great  trochanter  (Stimson). 


called  to  an  old  person  who  has  fallen,  be  it  in  ever  so  simple  a  way,  and 
who  suffers  pain  at  the  hip,  be  on  the  lookout  for  fracture  of  the  neck 
of  the  femur.  A  misstep  or  tripping  over  a  slight  obstacle  such  as  a 
mat,  or  even  an  attempt  to  prevent  a  fall,  is  sufficient  to  cause  this  frac- 
ture in  elderly  people.  The  young  and  middle-aged,  however,  are  not 
exempt,  but  in  them  a  greater  force  is  necessary  to  break  the  bone.  It 
is  more  common  in  women,  as  is  Colles's  fracture. 

The  old  classification  of  this  calamity  was  into  extra-  and  intra- 
capsular fracture.  This  does  not  cover  the  ground,  for  many  of  the 
cases  partake  of  the  characters  of  both  divisions.  It  is  better  to  speak 
of  fracture  at  the  small  part  of  the  neck  (Fig.  2i),  and  fracture  at  the 
base  of  the  neck  (Fig.  22).  The  practical  difference  between  these  two 
is  this  :  In  fracture  at  the  narrow  part  of  the  neck  impaction  rarely 
takes  place,  and  bony  union  is  possible,  but  not  probable.  In  fracture 
at  the  base  of  the  neck  impaction  is  the  rule  (often  with  rotation  out- 


78  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

ward),  and  bony  union  is  the  rule.  The  symptoms  of  both  are  the 
same. 

Exauii)iatiou. — The  patient  hes  in  bed  or  on  the  spot  where  he  fell, 
complaining;  of  great  pain  at  the  hip,  particularly  when  any  attempt  is 
made  to  move  him.  In  some  cases,  however,  the  pain  is  slight,  and 
the  limb  can  be  raised  from  the  bed.  This  is  where  there  is  impaction. 
It  is  possible  also  for  the  patient  to  walk. 

The  rule,  however,  is  that  the  limb  is  helpless,  and  as  it  rests  straight 
upon  the  bed  and  you  compare  it  with  the  other  limb,  the  foot  is  seen 
to  be  everted.  If  the  foot  is  not  everted,  you  will  find  the  patient 
cannot  evert  it  as  well  as  he  can  the  uninjured  member.  Impaction 
must  be  taken  into  account,  for  if  this  occur  with  the  limb  in  the  posi- 
tion of  inversion,  the  foot  will  remain  in  that  position.  The  thigh  at 
its  upper  part  has  an  unusual  fulness  and  roundness.  Pushing  the 
limb  upward  from  the  ankle  or  knee  produces  pain,  as  also  does  pres- 
sure upon  the  neck  or  the  trochanter.  Pressure  over  the  neck  of  the 
bone  in  front  shows  that  the  tissues  cannot  be  so  easily  depressed  as 
they  can  upon  the  other  side.  Measure  the  limb  from  the  anterior 
superior  spinous  process  to  the  outer  malleolus,  and  the  injured  limb 
will  show  a  shortening  of  one-fourth  of  an  inch  to  two  inches.  To 
prove  that  the  shortening  is  at  the  neck,  apply  Nekton's  measurement 
as  follows  :  From  the  anterior  superior  spinous  process  to  the  tuberosity 
of  the  ischium.  The  trochanter  on  the  injured  side  occupies  a  higher 
position  in  reference  to  this  line  than  does  its  fellow  of  the  opposite 
side.  Bryant's  line  can  next  be  used — viz.  around  the  pelvis  from  one 
anterior  spine  to  the  other.  The  distance  from  the  tip  of  the  trochanter 
to  this  line  will  be  found  shorter  on  the  injured  side. 

These  cases  are  fruitful  sources  of  malpractice  suits,  for  it  has  often 
happened  that  the  evidence  of  fracture  was  obscure ;  the  patient  was 
disabled,  but  the  injury  was  supposed  to  be  only  severe  bruising.  Do 
not  run  any  risk,  but  treat  it  as  a  fracture  if  you  are  in  any  doubt. 

Signs  of  Impaction. — The  foot  is  everted,  the  leg  is  shorter  than 
normal,  pain  is  localized,  and  there  is  marked  flattening  of  the  trochanter 
on  the  impacted  side.  When  these  conditions  are  present,  crepitus 
should  never  be  sought  for. 

Treatment. — Union  in  old  and  enfeebled  persons  is  doubtful.  Should 
they  show  the  bad  effects  of  confinement  to  bed,  we  must  make  the 
treatment  of  the  fracture  a  secondary  matter  and  attend  to  their  general 
health.  Traction  should  be  employed  gently,  and  impaction,  if  exist- 
ing, should  not  be  disturbed.  Make  the  patient  as  comfortable  as 
possible,  and  guard  against  bed-sores.  Sand-bags  or  cushions  may  be 
used  to  steady  the  limb,  or  a  plaster-of-Paris  cast  to  include  the  whole 
limb  and  the  pelvis.  Buck's  extension,  with  a  five-pound  weight,  will 
allow  the  patient  to  sit  up  in  bed,  and  will  keep  up  just  enough  trac- 
tion to  make  him  comfortable. 

Fracture  of  the  great  trochanter  may  occur  as  a  result  of  direct 
violence.  The  line  of  fracture  falls  outside  the  joint,  and  the  patients 
are  able  to  walk,  notwithstanding  the  injury. 

The  diagnosis  is  made  by  the  existence  of  localized  pain  and  by  the 
presence  of  a  fragment  which  moves  independently  of  the  shaft  of  the 
bone. 


INJURIES  AND  DISEASES   OF   THE    OSSEOUS  SYSTEM. 


79 


The  trcat)ncnt  is  immobilization  and  rest.  If  the  fragment  be  drawn 
upward  by  muscular  action,  a  bandage  accurately  applied  will  overcome 
this  tendency. 

Fracture  of  the  Shaft  of  the  Femur. — This  is  a  fracture  which 
answers  all  the  characteristics  of  fractures  in  general.  It  may  be  pro- 
duced by  any  of  the  ordinary  causes  of  fracture — direct  violence, 
indirect  violence,  or  muscular  action.  The  direction  of  the  line  of 
fracture  is  usually  oblique,  but  in  children  it  may  be  transverse  (Figs. 

23.  24). 

Symptoms. — As  the  patient  lies  in  bed  the  limb  shows  more  or  less 
deformity.  The  muscles  are  bunched  up  and  the  thigh  is  shortened. 
The  fragments  usually  o-verlap,  and  this  displacement  is  increased  by 


Fig.  23. — Transverse  fracture  of  the  shaft  of  the 
femur  immediately  beneath  the  trochanter. 


Fig.  24. — Fracture  of  neck  at  junction  with 
head. 


the  contraction  of  the  muscles.  The  foot  falls  outward  in  eversion, 
simply  from  its  weight.  When  an  attempt  is  made  to  lift  the  limb 
intense  pain  is  felt  and  abnormal  mobility  is  apparent.  Crepitus  is 
readily  detected,  but  the  other  symptoms  are  so  clearly  evidences  of 
fracture  that  this  symptom  is  unnecessary.  Measurement  from  the 
anterior  superior  spinous  process  to  the  outer  ankle  shows  shortening. 
Bryant's  and  Nelaton's  measurements  prove  that  this  shortening  is 
not  at  the  neck  of  the  femur.  When  the  hand  is  passed  over  the  seat 
of  fracture  and  the  limb  is  gently  raised,  the  abnormal  mobility  is  appar- 
ent. Grasp  the  thigh  gently,  rotate  the  limb  below,  and  you  will  find 
that  the  upper  portion  does  not  share  in  the  movement  of  the  lower. 

Treatment. — Make  steady  traction  until  the  shortening  is  overcome. 
Should  a  fragment  of  the  bone  pierce  the  muscle  and  skin,  flex  the 
thigh  upon  the  pelvis  and  the  leg  upon  the  thigh.  This  will  relax  the 
muscle  and  the  fragment  will  return  to  its  place.     Traction  contin- 


8o 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


uously  maintained  in  one  form  or  other  is  the  best  treatment,  and  the 
most  satisfactory  mode  of  traction  is  Buck's  extension.  The  extending 
force  is  a  weight  suspended  by  a  cord  which  passes  over  a  pulley. 
It  is  applied  in  the  following  manner :  Take  a  strip  of  strong  adhesive 


Fig.  25. — Adhesive  plaster  cut  for  Buck's  extension  (Stimson). 

plaster  four  inches  in  width  and  long  enough  to  reach  from  above  the 
knee  down  the  limb,  around  the  sole  of  the  foot  (where  it  is  left  loose), 
up  the  other  side,  opposite  to  the  place  of  beginning  (Fig.  25).  A  piece 
of  wood  five  inches  by  three  inches,  with  a  perforation  in  its  center,  is 


"V 


:x 


Fig.  26.— Adhesive  plaster  folded  for  Buck's  extension  (Stimson). 

placed  opposite  the  sole  of  the  foot,  and  the  adhesive  plaster  attached 
to  it  by  folding  its  edges  over  the  wood  (Fig.  26).  Through  the  open- 
ing in  the  wood  a  stout  cord  is  passed,  and  a  knot  tied  upon  it  to  pre- 
vent its  being  pulled  back  by  the  weight.     The  foot  and  lower  third  of 


Fig.  27. — Buck's  apparatus  with  Volkmann's  sliding  rest  for  fractures  of  the  thigh. 

the  leg  are  next  bandaged  by  a  roller  bandage ;  over  this  the  adhesive 
strips  are  applied  and  attached  to  the  sides  of  the  limb  as  far  as  they 
reach  up  the  thigh.  The  bandage  is  continued  upward  over  the  plasters, 
thus  supporting  them  against  the  limb.  The  cord  is  next  carried  over 
a  pulley  attached  to  the  foot  of  the  bed,  and  a  weight  varying  accord- 


INJURIES  AND   DISEASES    OF   THE    OSSEOUS  SYSTEM.  8 1 

ing  to  circumstances  is  attached  to  its  free  end.  The  weight  should 
run  about  a  pound  for  each  year  of  age  from  five  to  twenty.  To 
provide  for  counter-extension  the  foot  of  the  bed  is  raised.  To  pre- 
vent outward  rotation  the  most  convenient  appliance  is  Volkmann's 
sliding  rest  (Fig.  27).  It  is  formed  of  two  side-pieces  eight  inches  apart 
and  two  feet  in  length.  They  are  united  by  two  cross-pieces,  and  on 
these  rest  a  posterior  splint  and  foot-piece.  To  this  splint  the  leg  is 
attached.  Various  other  methods  of  treating  this  fracture  are  in 
vogue,  such  as  Cripp's  splint,  Nathan  R.  Smith's  anterior  splint, 
which  is  an  improvement  on  the  old  double  inclined  plane,  and 
Hodgen's  splint,  which  combines  the  principle  of  the  double  incHned 
plane  and  Buck's  extension.  The  two  latter  methods  are  of  great 
advantage  when  the  fracture  is  just  below  the  insertion  of  the  psoas 
and  iliacus,  and  counteract  the  bad  effect  of  tilting  forward  of  the  upper 
fragment,  which  is  common  in  fractures  at  this  part  of  the  femur. 

Fractures  of  the  Lower  End  of  the  Femur. — Fractures  at  the 
lower  end  of  the  femur  bear  a  close  analogy  to  those  at  the  lower  end 
of  the  humerus.  The  bone  may  be  broken  above  the  condyles  (supra- 
condylar). This  fracture  may  be  complicated  by  another  at  right 
angles  to  it  and  running  into  the  joint,  a  T-shaped  fracture ;  one  or 
other  of  the  condyles  may  be  detached,  and  lastly  the  epiphysis  may 
be  separated.  The  lower  end  of  the  femur  may  be  split  by  the  wedge- 
like action  of  the  patella. 

Supracondylar  and  T-shaped  Fracture. — The  direction  of  a  frac- 
ture just  above  the  condyles  is  generally  oblique,  and  the  especial 
danger  is  that  one  of  the  fragments  may  injure  the  popliteal  vessels. 
The  obliquity  is  generally  from  above  downward  and  forward.  The 
lower  fragment  is  rotated  by  the  gastrocnemius,  and  its  fractured  sur- 
face is  directed  backward.  If  while  the  fragment  is  in  this  position 
any  traction  be  made  upon  the  leg,  the  vessels  are  almost  sure  to  be 
injured.  When  the  displacement  is  in  the  opposite  direction — that  is, 
with  the  lower  fragment  projecting  forward — the  vessels  are  exposed  to 
danger  from  the  pressure  of  the  lower  end  of  the  upper  fragment. 

Diagnosis. — The  pain  and  deformity,  if  any,  are  lower  down  toward 
the  knee  than  in  other  fractures  of  the  shaft.  Shortening  is  usually 
apparent.  Even  with  impaction  the  symptoms  are  easily  recognized. 
When  the  fragments  are  free,  abnormal  mobility  and  crepitus  add  addi- 
tional testimony.  Grasp  a  condyle  in  each  hand,  and  if  the  fracture  is 
T-shaped  the  condyles  can  be  moved  backward  and  forward  upon  each 
other.  Besides  this,  they  are  spread  apart,  giving  the  appearance  of  a 
greater  width  to  the  lower  end  of  the  femur.  When  the  joint  is 
involved  another  important  sign  is  observed :  the  synovial  cavity 
becomes  distended  with  blood.  If  you  find  the  popliteal  space  rapidly 
filling  up  and  an  immense  swelling  forming,  and,  in  addition  to  this,  the 
leg  becoming  cold  and  pulseless,  you  may  know  that  the  popliteal 
artery  is  torn  and  bleeding  profusely  into  the  tissues.  When  the 
artery  is  simply  pressed  upon,  the  limb  also  becomes  cold,  but  this 
takes  place  gradually,  and  the  swelling  in  the  popliteal  space  is 
wanting. 

Treatment. — This  must  vary  according  to  the  conditions  present. 
Be  careful  in  making  extension  lest  the  vessels  become  pressed  upon 


82  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

or  torn.  Gentle  traction  with  direct  manipulation  is  generally  safe. 
When  the  upper  fragment  projects  backward,  Buck's  extension  is  a 
suitable  dressing.  When  the  lower  fragment  has  a  tendency  to  back- 
ward displacement,  the  gastrocnemius  is  the  disturbing  element  which 
must  be  disposed  of  This  can  be  done  either  by  dividing  the  tendo 
Achillis  or  by  treating  the  fracture  on  a  double  inclined  plane.  In 
general,  a  plaster-of-Paris  cast,  with  anterior  and  posterior  coaptation 
splints  under  the  plaster,  will  fulfil  all  the  requirements.  When  the 
knee-joint  is  involved,  the  effusion  and  swelling  must  be  got  rid  of  by 
pressure,  cold  applications,  and,  if  necessary,  by  aspiration.  Passive 
motion  of  the  joint  should  be  begun  not  later  than  the  end  of  the 
fourth  week. 

Laceration  of  the  popliteal  vessels  is  a  very  serious  complication. 
When  it  occurs  a  tourniquet  should  be  applied  to  the  femoral  artery, 
the  vessel  cut  down  upon  and  tied  above  and  below.  The  vein  should 
receive  careful  attention,  as  it  may  be  injured  as  well.  In  this  event 
amputation  is  the  only  treatment. 

Fracture  of  the  Patella. — A  fall  upon  the  knee,  or  a  fall  or 
blow  combined  with  a  strong  effort  on  the  part  of  the  patient  to  save 
himself,  is  likely  to  cause  fracture  of  the  patella.  The  direction  of  the 
fracture  is  generally  transverse.  The  line  may  be  across  the  middle 
or  near  the  upper  or  lower  end.  Sometimes  it  is  stellate  or  star-shaped, 
and  in  rare  cases  it  is  split  from  top  to  bottom.  An  oblique  fracture  is 
very  rare.  When  caused  by  direct  violence  the  fracture  is  often  either 
compound  from  the  first,  or  it  may  become  so  at  a  later  period  by 
sloughing  of  the  soft  parts  covering  the  bone.  When  the  fracture  is 
transverse  the  upper  fragment  is  drawn  upward  by  the  action  of  the 
quadriceps,  and  a  gap  exists  at  the  seat  of  fracture. 

It  fortunately  sometimes  happens  that  the  periosteum  remains  intact, 
and  thus  little  or  no  separation  takes  place. 

Symptoms. — After  such  an  accident  (a  fall  upon  the  knee,  a  blow, 
or  struggle  to  avoid  falling)  pain  is  felt  over  the  patella,  and  the  patient 
cannot  extend  the  leg.  The  fragments  are  independently  movable,  and 
a  distinct  transverse  gap  exists  between  them,  which  can  be  closed  up 
by  moving  the  fragments  toward  each  other. 

Treatment. — If  the  periosteum  has  not  given  way  and  there  is  little 
or  no  separation,  a  plaster-of-Paris  cast  from  the  ankle  to  the  upper 
third  of  the  thigh  is  a  good  dressing.  With  wide  separation  something 
more  than  this  is  necessary.  A  long  list  of  appliances  might  be  named 
to  meet  the  requirements  of  these  cases.  A  posterior  splint  is  applied, 
and  by  oblique  turns  of  a  roller  bandage  the  fragments  are  maintained 
in  their  proper  position.  The  patient  must  keep  his  bed  with  the 
foot  raised,  thus  counteracting  the  action  of  the  quadriceps  extensor 
tendon. 

A  very  useful  and  easily  constructed  appliance  is  Agnew's  splint 
(Fig.  28).  A  piece  of  board  thirty  inches  long,  five  inches  wide  at  one 
end  and  four  at  the  other,  is  slightly  hollowed  out  to  fit  the  thigh  and 
calf,  leaving  the  middle  plain  to  correspond  with  the  flat  surface  behind 
the  knee.  Four  pegs  are  fitted  into  the  sides  in  such  positions  as  to 
give  attachment  to  the  bandage  which  draws  the  fragments  together. 
The  method  of  its  application  is  seen  in  Fig.  29. 


INJURIES  AND  DISEASES   OF  THE    OSSEOUS  SYSTEM.  83 

Should  the  above  methods  fail  or  should  it  be  found  impossible 
from  the  first  to  keep  the  fragments  in  apposition,  operative  measures 
should  be  resorted  to.  Sev^eral  operative  procedures  have  from  time  to 
time  been  employed — for  instance  : 

1.  Open  arthrotomy,  with  suturing  of  the  fragments  with  silver 
wire.  This  has  been  very  successful  in  a  large  number  of  cases. 
It  has  led  to  suppuration  and  fatal  results  have  been  reported.  Under 
strict  antisepsis  and  in  healthy  subjects  the  risk  to  be  run  need  not  be 
considered  great.  The  operation  consists  in  making  a  free  incision 
across  the  patella  to  expose  the  fragments.  If  the  fracture  is  an  old 
one,  the  broken  surfaces  must  next  be  freshened.  Any  fibrous  tissue 
which  has  recently  formed,  or  any  fascia  or  other  tissue  which  has 
come  between  the  fragments,  should  be  carefully  removed.  Holes  are 
drilled  into  the  bone  by  directing  the  drill  through  the  anterior  surface 
of  each  fragment  obliquely  from  the  attached  border  toward  the  poste- 
rior edge  of  the  fractured  surfaces.  Three  sutures  of  silver  wire  are 
sufficient,  and  when  perfect  approximation  has  been  effected  the  ends 
of  the  wire  are  cut  off,  and  either  hammered  into  the  bone  or  left  pro- 
truding from  the  wound  to  be  withdrawn  later. 

2.  Subcutaneous  suture  has  proved  satisfactoiy  and  is  easily  per- 


FlG.  28. — Agnew's  splint  for  fractured  patella.  FiG.  29. — Agnew's  splint  applied. 

formed.  The  method  is  as  follows  :  After  thorough  disinfection  of  the 
limb  a  long,  half-curved  Hagedorn  needle,  carrying  a  strong  silk 
suture,  is  inserted  at  one  side  of  the  ligamentum  patellae,  and  carried 
through  the  ligament  to  the  corresponding  point  on  the  other  side ; 
the  needle  is  then  reinserted  at  the  latter  point,  and  carried  up  along 
the  edge  of  the  fragments  to  a  point  above  the  patella,  then  through 
the  tendon  of  the  quadriceps  to  the  corresponding  point  on  the  other 
side,  and  back  to  the  place  of  beginning.  The  fragments  are  now 
accurately  approximated  by  means  of  tenacula,  the  suture  drawn 
tight,  tied,  the  ends  cut  off,  and  the  knot  pushed  beneath  the  skin. 
The  knee  is  dressed  antiseptically,  and  placed  upon  a  posterior  splint 
for  one  week,  after  which  a  plaster-of-Paris  cast  is  worn  for  a  month 
constantly,  and  for  another  month  during  the  daytime. 

Barker's  operation  is  probably  an  improvement  on  the  ordinary 
subcutaneous  suture.  The  method  of  operating  is  as  follows:  With 
the  finger  and  thumb  of  the  left  hand  steady  the  lower  fragment,  and 
at  its  lowest  point  in  the  middle  line  of  the  ligamentum  patellae  make 
a  small  incision  by  means  of  a  narrow-bladed  knife  through  the  skin 
and  into  the  joint.  Through  this  opening  a  stout-handled  pedicle-needle 
is  passed  into  the  joint  behind  both  fragments.  The  upper  fragment  is 
now  pushed  down  as  closely  to  the  lower  as  possible,  and  the  needle 
thrust  through  the  quadriceps  tendon  at  the  upper  edge  of  the  frag- 
ment.   The  point  of  the  needle,  becoming  apparent  beneath  the  skin,  is 


84 


SURGICAL    DIAGNOSIS  AND    TREATMENT. 


cut  down  upon  and  pushed  to  the  surfece.  A  stout  silk  thread  is  passed 
into  the  eye  of  the  needle,  which  is  withdrawn,  carrying  the  thread 
behind  the  fragments  (Fig.  30).  The  end  of  the  thread  is  withdrawn 
from  the  needle's  eye  and  left  emerging  from  the  lower  opening.  Again 
the  needle  is  passed  through  the  lower  opening,  but  this  time  it  is  made 
to  pass  in  front  of  both  fragments  and  out  at  the  upper  opening.  It  is 
threaded  with  the  upper  end  of  the  silk  and  withdrawn,  leaving  the 
thread  in  front  of  the  fragments  (Fig.  31).  The  fragments  are  approx- 
imated and  rubbed  against  each  other  to  displace  clots ;  the  ligature  is 
securely  tied,  cut  off  short,  and  the  wounds  closed.  The  bone  unites, 
in  the  great  majority  of  cases,  by  fibrous  tissue,  and  on  this  account 
the  after-treatment  is  more  important  in  this  fracture  than  perhaps  in 
any  other.  Although  the  separation  of  the  fragments  may,  at  the 
outset,  be  to  the  extent  of  only  half  an  inch,  it  is  not  uncommon  to 
have  this  distance  increase  until,  at  the  end  of  several  months,  it  may 


Fig.  30. — Barker's  operation  for  transverse 
fracture  of  the  patella  (first  stage). 


Fig.  31. — Barker's  operation  for  transverse 
fracture  of  the  patella  (second  stage). 


reach  five  or  even  six  inches.  This  may  be  explained  in  two  ways — 
either  that  no  union  has  taken  place  at  all,  or  the  newly-formed  fibrous 
tissue  has  been  stretched  by  allowing  the  use  of  the  knee  at  too  early 
a  period.  In  all  cases  of  transverse  fracture  perfect  immobilization 
of  the  knee  should  be  maintained  for  eight  weeks,  after  which  an 
apparatus  should  be  worn  to  prevent  flexion  for  six  months.  The 
stiffness  in  the  knee  resulting  from  such  long-continued  disuse  passes 
off  gradually,  and  the  fibrous  tissue  becomes  so  firm  that  it  will  not 
stretch. 

Fractures  of  the  Leg-. — The  weakest  part  of  the  tibia  is  at  the 
junction  of  the  middle  and  lower  thirds,  and  here  it  is  most  frequently 
broken.  When  both  bones  are  fractured  the  fibula  gives  way  higher 
up.  Comminuted  fracture  is  common  even  when  the  cause  is  indirect 
violence.  The  tibia,  for  a  considerable  portion  of  its  length,  is  covered 
by  little  more  than  skin,  and  on  this  account  it  is  specially  liable  to 


INJURIES  AND   DISEASES   OF   THE    OSSEOUS  SYSTEM.  85 

compound  fracture.  When  both  bones  are  broken  by  direct  violence, 
it  is  generally  on  the  same  level  and  the  direction  is  transverse.  When 
the  violence  is  indirect  the  fracture  is  oblique  and  the  fragments  are 
pointed.  Beware  of  letting  a  patient  attempt  to  walk  when  there  is 
suspicion  of  such  a  fracture,  for  there  may  be  no  apparent  deformity 
until  his  weight  comes  upon  the  limb.  Then  the  oblique  fragments 
slip  past  each  other,  and,  perforating  the  skin,  a  compound  fracture  is 
the  result. 

Symptoms. — Deformity  is  generally  so  clearly  marked  as  to  be 
apparent  at  the  first  glance.  Pain  is  a  prominent  symptom,  and  is  greatly 
intensified  on  the  slightest  pressure.  If  the  patient  has  to  be  moved 
from  the  scene  of  the  accident,  be  careful  to  secure  the  limb,  lest  the  skin 
give  way.  A  pillow  placed  lengthwise  under  the  leg  and  tied  around 
with  several  handkerchiefs  makes  a  very  soft  and  easy  applicance, 
while  firmness  can  be  given  by  placing  strips  of  lath,  shingle,  or  similar 
pieces  of  wood  at  each  side  and  behind. 

Treatment. — A  fracture-box  slung  from  a  cradle  is  a  very  comfort- 
able apparatus  for  this  fracture,  but  the  most  convenient  of  all  is  a 
plaster-of-Paris  cast.  The  form  known  as  the  Bavarian  splint  makes  an 
excellent  dressing.  It  is  thus  employed :  Take  two  pieces  of  flannel 
(coarse  house  flannel  is  the  be.st)  long  enough  to  reach  from  the 
popliteal  space  to  the  balls  of  the  toes,  and  three  inches  wider  than  the 
circumference  of  the  limb  ;  sew  them  together  down  the  middle  line  for 
the  length  of  the  leg ;  for  the  remainder  of  their  length  they  are  cut  in 
two,  to  be  applied  to  the  foot.  Place  the  leg  upon  the  flannel,  so  that 
the  seam  runs  down  the  back  and  ends  at  the  heel ;  fold  the  inner 
layers  over  and  fasten  them  together  down  the  front.  Keeping  the 
foot  exactly  at  a  right  angle,  fold  the  end-pieces  over  it.  Now  place 
the  leg  upon  one  side  and  you  are  ready  for  the  plaster.  The  plaster 
should  be  mixed  to  the  consistence  of  cream.  Spread  over  the  inner 
layer  from  the  seam  behind  to  the  place  where  it  is  folded  in  front,  and 
press  the  outer  one  down  upon  this  before  it  has  time  to  set.  As  soon 
as  this  has  become  firm  turn  the  leg  over  and  repeat  the  proceeding 
upon  the  other  side.  When  the  plaster  has  properly  set  undo  the 
fastening  in  front ;  you  now  have  two  side-splints  admirably  moulded 
to  the  leg  and  united  by  a  hinge  formed  by  the  seam  at  the  back.  All 
that  remains  now  is  to  trim  off  the  edges  and  fasten  the  inner  layer 
down  to  the  outer  on  the  surface  of  the  splint. 

Fracture  of  the  Tibia  Alone. — The  only  difficulty  in  diagnosis  of 
fracture  of  the  tibia  alone  is  when  the  bone  is  broken  transversely, 
and  where  the  swelling  prevents  our  feeling  the  crest.  Under  other 
circumstances  fracture  of  the  tibia  is  readily  diagnosed.  The  inner 
malleolus  may  be  broken,  the  tubercle  torn  off  by  the  action  of  the 
quadriceps,  and  the  spine  or  the  head  of  the  bone  broken  off  or  split 
by  the  action  of  the  crucial  ligaments  in  violent  twists  of  the  knee. 
False  joint  is  liable  to  occur  in  fracture  of  this  bone  if  the  patient  has 
been  attempting  to  walk  or  if  complete  immobilization  of  the  fracture 
has  not  been  maintained.  Fracture  of  the  upper  end  of  the  tibia  is 
often  transverse,  and  when  so  is  the  result  of  direct  violence.  The  soft 
parts  are  contused.  The  fracture  may  take  the  form  of  a  T  inverted, 
the  vertical  part  extending  into  the  joint,  causing  synovitis.     The  frag- 


86  SURGICAL   DIAGNOSIS  AXD    TREATMENT. 

ments  may  be  separated  by  a  blood-clot  which  may  extend  into  the 
synovial  sac. 

Tiratiiicnt  for  Fracture  of  this  Form. — Apply  cold  compresses  to 
remove  effusion  and  swelling.  The  leg  should  be  put  up  in  the  double 
inclined  plane,  care  being  taken  not  to  have  the  incline  too  acute,  as 
the  upper  fragment  may  protrude  through  the  skin,  thus  creating  a 
compound  fracture.  When  the  joint  is  not  implicated  a  plastcr-of- 
Paris  bandage  will  suffice.  If  there  are  good  reasons  for  keeping  the 
leg  uncovered,  then  one  splint  (Cline's)  on  the  inner  side  of  the  leg  will 
do,  as  the  fibula  when  intact  will  serve  as  a  splint  on  the  external  side. 

Fracture  of  the  Fibula  Alone. — This  is  sometimes  called  the 
"railroad  fracture"  or  "street-car"  fracture,  because  it  is  so  com- 
monly caused  by  jumping  from  a  vehicle  in  motion.  When  a  person 
jumps  from  a  rapidly-moving  street-car,  and  comes  forcibly  upon  his 
feet  with  the  toes  pointing  at  right  angles  to  the  line  in  which  he  was 
moving,  a  severe  strain  is  thrown  upon  the  fibula.  Either  the  lateral 
ligaments  of  the  ankle  or  the  bone  must  yield,  and,  as  usual  when  a 
contest  between  ligament  and  bone  occurs,  the  bone  is  found  to  be  the 
weaker  structure  and  is  forced  to  give  way.  The  bone  may  also  be 
broken  at  any  part  by  direct  violence  and  by  violent  contraction  of  the 
biceps  muscle. 

Diag)iosis. — Wlien  the  fracture  is  at  the  upper  end  it  is  due  to 
muscular  action,  except  when  caused  by  direct  violence.  The  displace- 
ment, if  any,  is  a  drawing  upward  and  backward  of  the  upper  fragment 
by  the  biceps.  Fracture  in  this  part  of  the  bone  is  of  interest,  owing 
to  the  liability  to  injury  of  the  peroneal  nerve  either  at  the  time  of  the 
accident  or  later  by  being  caught  in  the  callus.  This  complication  is 
recognized  by  pain  along  the  nerve  or  paralysis  of  the  peroneal  group 
of  muscles.  When  the  shaft  is  broken  the  displacement  is  angular 
and  the  fragments  overriding,  with  the  lower  end  of  the  upper  fragment 
forward.  The  prominent  symptoms  are  pain  and  tenderness  at  one 
particular  spot.  Mobility  is  difficult  to  recognize,  and  crepitus  often 
impossible.  To  examine  the  bone  press  alternately  with  the  thumbs 
side  by  side  over  the  seat  of  injury  or  forcibly  twist  the  foot.  In  this 
way  mobility  and  crepitus  may  be  found,  and,  even  if  they  are  not,  the 
loss  of  the  natural  spring  of  the  fibula  will  be  wanting.  Instead  of 
springing  back  to  its  place,  it  will  yield  before  the  pressure.  The 
weakest  spot  in  the  fibula  is  two  to  four  inches  above  the  ankle,  and 
this  is  the  commonest  seat  of  fracture.  To  this  special  form  the  name 
of  Pott's  fracture  is  given.  Forcible  eversion  and  abduction  or  in- 
version and  adduction  will  produce  it.  In  the  typical  Pott's  fracture 
three  separate  lines  of  fracture  exist :  first,  the  fibula,  two  to  four 
inches  above  the  upper  part  of  the  malleolus ;  second,  the  inner  mal- 
leolus ;  third,  the  outer  lower  edge  of  the  tibia.  The  prominent  symp- 
tom is  the  displacement  of  the  whole  foot  outward,  carrying  with  it  the 
external  malleolus,  which  is  thus  separated  from  the  fibula.  The  internal 
malleolus  is  thus  rendered  very  prominent.  Three  points  of  localized 
pain  can  be  found,  corresponding  to  the  three  lines  of  fracture  above 
mentioned.  The  skin  over  the  inner  malleolus  is  stretched,  and  may 
even  be  perforated  by  that  bony  point.  The  foot  moves  too  freely 
from  side  to  side  in  the  space  between  the  tibia  and  fibula,  which  is 


INJURIES  AND   DISEASES    OF   THE    OSSEOUS  SYSTE.^f.  8/ 

now  greatly  widened.  In  some  cases  the  foot  slips  backward,  so  that 
the  body  of  the  astragulus  lies  behind  the  tibia. 

Treatment. — For  fracture  of  the  upper  end  all  that  is  needed  is 
immobilization  with  the  knee  flexed  in  order  to  relax  the  biceps.  In  the 
shaft  any  displacement  must  be  reduced  by  traction  and  direct  manipu- 
lation. Immobilization  by  a  Volkmann's  splint  for  a  day  or  two,  and 
then  by  a  plaster-of-Paris  cast,  will  give  good  results. 

Pott's  fracture  requires  particular  care,  for  the  displacement  is 
greater  and  the  deformity  is  more  liable  to  return  than  in  any  other 
fracture  of  the  fibula.  Grasp  the  leg  firmly  with  one  hand  and  the  foot 
with  the  other.  Draw  the  foot  forward  and  inward  until  the  astragalus 
can  be  felt  lying  up  against  the  internal  malleolus.  Be  careful  to  cor- 
rect any  backward  displacement,  for  this  is  often  overlooked. 

Dupuytren's  splint  has  had  a  long  and  useful  career  in  the  treat- 
ment of  this  fracture.  It  is  a  lateral  splint  applied  to  the  inside  of  the 
leg  and  extending  two  or  three  inches  below  the  foot.  A  wedge- 
shaped  pad  is  placed  between  the  splint  and  the  leg,  the  thick  end  of 
the  wedge  being  a  little  above  the  malleolus.  By  means  of  a  roller 
bandage  the  foot  is  drawn  well  toward  the  tibia,  and,  continuing  the 
bandage  up  the  leg,  immobilization  is  secured. 

A  neater  and  more  steady  appliance  can  be  secured  by  moulded 
plaster-of-Paris  splints.  The  first  of  these  is  applied  along  the  back  of 
the  leg  from  just  below  the  knee  to  the  heel,  along  the  sole  of  the  foot 
and  beyond  the  toes ;  the  second  begins  on  the  dorsum  of  the  foot, 
runs  obliquely  to  the  outer  side  under  the  sole,  and  up  the  inner  side 
of  the  leg.  Circular  turns  secure  the  splints  just  above  the  ankle  and 
below  the  knee.  Care  must  be  taken  to  keep  the  foot  in  good  position 
while  the  plaster  is  setting. 

Fracture  of  the  External  Malleolus. — An  in\\ard  twist  of  the  foot 
will  cause  the  astragalus  to  force  the  malleolus  outward  and  produce 
fracture.  It  gives  way  about  an  inch  or  an  inch  and  a  half  above  the 
end  of  the  bone. 

Diagnosis. — Tenderness  and  pain  on  pressure  and  when  the  foot  is 
turned  inward  are  the  chief  symptoms  ;  abnormal  mobility  and  crepitus 
are  not  readily  found. 

TreatnieJit. — Immobilization. 

Fracture  of  the  Astragalus. — Diagnosis  is  uncertain,  except  where 
there  is  also  dislocation  or  when  the  fracture  is  compound.  If  the 
latter,  it  is  best  to  remov^e  the  fragments  when  displaced,  as  good 
results  follow  their  removal. 

The  calcaneum  may  be  broken  by  a  fall  or  by  muscular  action. 
When  caused  by  the  latter  a  fragment  is  broken  off  and  carried  upward 
by  the  action  of  the  powerful  muscles  of  the  calf  When  caused  by 
direct  violence  the  fracture  is  generally  comminuted.  Have  the  patient 
kneel  and  then  compare  the  heels.  The  injured  one  is  flattened  and 
broadened,  and  the  tendo  Achillis  is  relaxed. 

The  treatment  is  massage  and  immobilization,  with  use  of  the  limb 
as  early  as  possible. 

The  metacarpal  bones,  when  fractured,  present  few  difficulties. 
Pressure  at  the  broken  point  causes  pain,  as  also  pressing  of  the  cor- 
responding toe  backward.     In  the  first   and    fifth   toes   crepitus    and 


88  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

mobility  are  usually  present.  The  displacement  is  so  slight  that  in 
simple  cases  all  that  is  needed  is  rest,  with  the  foot  elevated,  and 
massage. 

Compound    Fractures. 

The  diagnosis  of  compound  fractures  presents  no  special  difficulty. 
In  no  department  of  surgical  practice  is  better  judgment  or  more 
prompt  action  required  than  in  their  treatment.  It  is  here  that  modern 
surgery  has  obtained  some  of  its  most  brilliant  results.  In  uncom- 
plicated cases  a  thoroughly  antiseptic  dressing  converts  a  compound 
into  what  is  practically  a  simple  fracture.  The  first  dressing  is  of  the 
utmost  consequence,  for  upon  it  depends  to  a  \&xy  great  extent  the 
success  or  failure  of  treatment. 

When  the  fracture  is  the  result  of  indirect  violence,  or  when  a  sim- 
ple has  been  converted  into  a  compound  fracture  by  niiduc  movement  of 
the  fragments,  there  is  little  injury  to  the  soft  parts.  In  a  compound 
fracture  by  direct  violence  there  is  usually  bruising,  crushing,  or  lacera- 
tion, which  adds  to  the  seriousness  of  the  injury.  The  dressing  in  this 
form  of  fracture  should  be  as  carefully  carried  out  as  the  details  of  a 
major  operation.  All  instruments  that  are  likely  to  be  required  should 
be  disinfected  ;  the  parts  in  the  neighborhood  of  the  wound  should  be 
washed  and  sterilized,  as  in  any  other  operation.  Most  cases  require 
anesthesia.  The  wounded  tissues  demand  the  utmost  care  in  their 
purification.  If  plastered  wdth  dirt,  machinery-grease,  and  other  foreign 
substances,  olive  oil  should  be  applied,  followed  by  alcohol,  s.oap  and 
water,  and  corrosive-sublimate  solution,  i  :  2000.  Shreds  of  tissue  or 
structures  which  cannot  possibly  retain  their  vitality  should  be  cut 
away ;  splinters  and  broken-off  pieces  of  bone  should  be  removed ; 
bleeding  vessels  should  be  ligated  and  all  hemorrhage  stopped.  Bear 
in  mind  that  to  leave  a  nerve,  a  muscle,  or  a  tendon  unsutured  is  as 
gross  a  piece  of  negligence  as  to  leave  a  fracture  unreduced.  Having 
attended  to  all  these  matters,  the  fracture  is  next  in  order.  Before  reduc- 
tion of  the  fragments  can  be  effected  they  may  have  to  be  trimmed  off 
by  bone-forceps  or  even  a  portion  removed  by  a  saw.  Drainage  must 
be  secured  by  counter-openings,  if  necessary,  and  the  cutaneous  wound 
sutured.  A  copious  antiseptic  dressing  is  applied,  and  a  retentive 
apparatus  suitable  for  the  particular  fracture.  When  possible,  an  ap- 
pliance which  allows  dressing  of  the  wound  without  disturbing  the 
splints  should  be  employed.  Plaster  of  Paris  can  be  made  to  fulfil  most 
indications,  and  suspension  is  also  a  valuable  aid.  If,  in  spite  of  all  our 
care,  suppuration  takes  place,  the  wound  must  be  dressed  daily, 
thorough  drainage  established,  and  the  parts  brought  into  an  aseptic 
condition  as  speedily  as  possible. 

Amputation  after  Injury. 

One  of  the  most  perplexing  questions  for  the  surgeon  to  meet  is 
"when  to  amputate."  No  rules  can  be  laid  down,  for  each  case  must 
be  judged  upon  its  merits.  A  consideration  of  the  following  points 
may  help  us : 

I.  Is  the  blood-supply  permanently  cut  off?    When  the  main  artery 


INJURIES  AXD   DISEASES   OF   THE    OSSEOUS  SYSTEM. 


89 


and  its  accompanying  veins  are  destroyed,  gangrene  is  sure  to  follow 
an  attempt  to  sa\'e  the  limb  (Fig.  32).  When  the  artery  alone  is  lost, 
the  collateral  circulation  may  be  trusted  to  nourish  the  part. 

2.  Are  the  tissues  devitalized  ?  The  soft  parts  may  be  extensively 
cut  up,  and  yet  if  they  are  incised  wounds  good  apposition  of  the  dif- 
ferent structures  may  be  obtained  and  the  part  may  be  saved.  It  is 
different  if  the  parts  are  crushed  and  mangled.  The  wheels  of -a 
heavy  railway  car  in  running  ov^er  a  limb  not  only  comminute  the 
bone,  but  crush  the  very  life  out  of  muscles,  nerves,  vessels,  and  ten- 
dons. The  same  may  be  said  of  powerful  machinery.  The  skin  may 
reriiain  intact  and  show  nothing  more  than  an  unusual  paleness,  but  it 
soon  sloughs,  and,  together  with  the  deeper  parts,  becomes  gangrenous. 

3.  Is  it  possible  to  prevent  suppuration  and  septic  infection  ?  As  a 
rule,  this  question  can  be  answered  in  the  affirmative.  A  thorough 
purification   of  these   parts,  followed  by  a  careful   antiseptic   dressing 


Fig.  32. — Gunshot  wound  of  forearm  ;  circulation  cut  off  (from  a  photograph  in  the  collection 
of  Dr.  Lincoln,  Wabasha,  Minn.). 

with  provision  for  drainage,  will  warrant  us  in  attempting  to  save 
limbs  which  in  preantiseptic  days  would  have  been  sacrificed.  In 
cases  of  doubt,  therefore,  we  can  wait  a  few  days  without  exposing  the 
patient  to  great  risk. 

4.  If  saved,  will  the  limb  be  useful  ? 

5.  Do  the  age  and  general  condition  of  the  patient  admit  of  saving 
the  limb  ?  In  children  we  can  attempt  much  more  than  in  adults. 
The  kidneys  should  receive  careful  attention.  If  the  urine  is  of  low 
specific  gravity  or  contains  albumin,  the  chances  of  saving  the  limb 
are  very  much  lessened. 

II.    DISEASES   OF   BONE. 

Inflattimation. — From  a  clinical  standpoint  the  composition  of 
bone    differs    from   other    parts    in   only  one    particular — namely,  the 


90  SURGICAL    DIAGNOSIS  AND    I'REATMENT. 

presence  of  lime  salts,  which  give  firmness  and  hardness  to  the  structure. 
The  pathological  changes  are  the  same  in  inflammation  of  bone  as  in 
other  tissues  of  the  body — viz.  hyperemia,  dilatation  of  the  blood- 
vessels, increased  rapidity  of  the  circulation  followed  by  stasis.  Lymph 
pours  out  through  the  walls  of  the  vessels,  the  tissues  become  en- 
gorged, but  swelling  can  take  place  only  to  a  very  limited  degree. 
Pain  is  more  acute  and  persistent,  because  the  products  of  inflanmiation 
are  confined  by  unyielding  tissue,  which  does  not  allow  of  expansion. 
Pus,  when  formed,  is  long  retained,  because  its  pressure  does  not  cause 
atrophy  rapidly,  and  it  cannot  get  to  the  surface  as  readily  as  is  the 
case  in  soft  tissues. 

Any  one  of  the  three  structures  of  which  a  bone  is  composed  may 
be  the  seat  of  inflammation — viz.  the  periosteum  (periostitis),  the  bony 
tissue  (ostitis),  and  the  medulla  (myelitis).  Periostitis  alone  very  rarely 
occurs,  and  the  same  is  true  of  myelitis.  The  bony  tissue  is  affected  in 
either  case.     So  we  speak  of  osteoperiostitis  and  osteomyelitis. 

Inflammation  is  due  to  a  variety  of  causes  : 

1.  The  result  of  injury.  More  or  less  inflammation  attends  every 
fracture.     There  is  in  this  case  no  suppuration. 

2.  The  presence  of  pyogenic  organisms.  The  staphylococcus  aureus 
and  the  streptococcus  pyogenes  are  the  germs  most  commonly  found. 
They  may  find  a  portal  of  entrance  by  an  open  wound,  by  the  blood- 
stream which  carries  them  from  a  distant  pus-depot,  by  the  lungs,  or  by 
the  digestive  tract.  The  presence  of  these  germs  produces  inflam- 
mation  with  suppuration. 

3.  A  general  infective  disease,  such  as  typhoid  fever. 

4.  Special  diathetic  states,  as  syphilis  and  tuberculosis.  These  two 
are  not  attended  with  suppuration,  but  liquefaction  is  quite  common. 

Osteoperiostitis. — Most  of  the  cases  of  periostitis  (so  called)  come 
under  this  head,  for  when  the  periosteum  is  inflamed  the  superficial 
layers  of  the  bone  are  also  involved.  The  common  causes  are  exposure 
to  cold  and  wounds  or  contusions.  The  bones  which  are  the  most 
superficial  are  those  most  likely  to  suffer,  and  on  this  account  diagnosis 
is  more  simple.  In  no  class  of  cases,  however,  are  errors  more  fre- 
quently made,  and  the  results  are  often  serious.  If  the  condition  is  not 
recognized  and  promptly  treated,  the  periosteum  becomes  thickened, 
the  vessels  going  to  supply  the  underlying  bone  become  occluded,  pus 
or  inflammatory  products  separate  the  periosteum  from  the  bone,  and 
death  of  bone  follows.  Prompt  treatment  prevents  all  this,  and  allows 
the  parts  quickly  to  resume  their  healthy  condition. 

Diaf^nosis. — The  bone  most  commonly  affected  is  the  tibia.  When 
the  inflammation  is  non-suppurative,  the  constitutional  .symptoms  are 
not  prominent.  There  is  always  pain,  and  it  is  worse  at  night.  Pass 
your  fingers  over  the  painful  part :  the  pain  is  increased  on  pressure, 
and  more  or  less  swelling  can  be  detected,  giving  the  bone  a  spindle 
shape.  The  soft  parts  covering  the  bone  are  red  and  edematous. 
When  there  is  suppuration  there  are  marked  fever,  often  chills,  and 
severe  constitutional  disturbance. 

Treatment. — Keep  the  part  at  rest,  and  apply  cold  or  warmth  as  the 
patient  finds  one  or  the  other  more  comfortable.  If  the  symptoms 
continue,  puncture  the  part  in  several  places  with  a  disinfected  needle. 


INJURIES  AND   DISEASES   OF   THE    OSSEOUS  SYSTEM.  9I 

When  suppuration  is  taking  place,  lay  the  part  freely  open  by  an 
incision  down  to  the  bone  and  through  the  thickened  periosteum. 
This  should  be  followed  by  a  moist  antiseptic  dressing.  When  syphilis 
is  the  cause  of  the  disease,  the  constitutional  treatment  of  syphilis 
should  be  carried  out,  and  incisions  are  unnecessary. 

Osteomyelitis. — This  is  the  most  common  form  of  inflammation 
in  bone.  The  medulla  is  rarely  affected  alone,  and  hence  myelitis  need 
not  be  considered  clinically.  Both  bone  and  medulla  are  simultaneously 
affected,  and  we  name  the  condition  osteomyelitis.  The  inflammation 
may  be  local,  general,  or  septic.  Slight  injuries  may  produce  inflam- 
mation of  bone  which  ends  by  resolution,  leaving  the  bone-layers 
unchanged.  In  the  severer  forms,  and  particularly  in  chronic  inflam- 
mation, destruction  of  bone  takes  place.  If  death  of  bone  occurs  in 
mass,  it  is  called  necrosis  ;  if  it  is  molecular,  we  call  it  caries. 

Septic  Inflammation  of  Bone. — This  occurs  under  two  condi- 
tions. The  first  variety  is  seen  in  adults  and  is  associated  with  an 
open  wound.  Before  the  days  of  antiseptic  surgery,  amputations,  com- 
pound fractures,  and  many  cases  of  open  wound  connected  with  bone 
were  followed  by  septic  osteomyelitis.  Fortunately,  these  cases  are 
now  comparatively  rare.  After  amputation  in  which  septic  infection 
of  the  bone  takes  place,  the  medulla  is  observed  to  be  discolored, 
bleeding  readily  and  protruding  beyond  the  bone,  so  as  to  form  a 
fungus-like  growth.  The  discharge  is  abundant,  sero-purulent,  and  of 
a  very  offensive  odor.  In  very  severe  cases  the  destructive  process  is 
rapid,  and  the  patient  dies  of  pyemia  or  septicemia  in  two  or  three 
days. 

The  second  variety  is  a  disease  especially  common  in  childhood.  It 
occurs  without  wound  or  fracture,  and  has  its  starting-point  at  or  near 
the  epiphyseal  line.  The  femur  and  the  tibia  are  the  bones  most  com- 
monly affected.  Boys  suffer  three  times  as  often  as  girls.  About  half 
the  patients  are  between  thirteen  and  seventeen  years  of  age.  The 
pyogenic  germs  gain  access,  not  by  an  open  wound,  but  by  the  vascular 
or  lymphatic  system. 

Diagnosis. — Although  the  symptoms  of  osteomyelitis  are  generally 
very  plain,  the  most  serious  errors  in  diagnosis  are  quite  common.  A 
young  adult  is  seized  with  intense  pain  in  the  thigh,  and  in  a  ver>'  high 
fever  is  compelled  to  lie  in  bed.  A  careless  practitioner  may  diagnose 
his  case  as  rheumatism,  forgetting  that  acute  rheumatism  attacks  the 
joints,  and  not  the  shafts  of  the  long  bones,  and  that  it  is  seldom  con- 
fined to  a  single  joint.  Weeks  or  months  later  a  large  portion  of 
necrosed  femur  has  to  be  removed  by  operation.  Sometimes  the 
febrile  symptoms  impress  the  attendant  to  the  exclusion  of  local  con- 
ditions, and  a  diagnosis  of  typhoid  fever  is  made.  Another  case  may 
show  marked  redness  of  the  skin,  which  of  itself  is  sufficient  to  lead 
some  persons  to  a  diagnosis  of  erysipelas.  Except  in  the  early  hours 
or  days  of  the  disease  these  mistakes  are  unpardonable. 

The  syjnptonis  are — 

1.  High  fever,  with  or  without  a  chill.  The  temperature  is  high 
from  the  beginning,  and  does  not  show  the  gradual  daily  increase  with 
morning  remissions  so  characteristic  of  typhoid  fever. 

2.  Pain  of  a  peculiar  gnawing  or  boring  character,  worse  at  night. 


92  si'NG/CA/.  d/.h;\os/s  and  treatment. 

This  pain  is  situated  in  the  shaft  of  the  bone  near  a  joint,  but  not  in 
the  joint.  Movement  causes  intense  pain,  due  to  the  action  of  the 
muscles  upon  the  inflamed  area,  and  not  to  friction  in  the  joint.  There 
is  ahvays  sensitiveness  on  pressure. 

3.  Changes  in  the  overlying  parts.  When  the  inflamed  area  is 
deeply  seated  no  change  in  the  soft  parts  is  observed  in  the  early 
stage  of  the  disease.  After  several  days  the  superficial  layers  of  bone 
become  affected,  then  the  periosteum,  and  lastly  the  overlying  soft 
parts.  By  this  time  the  swelling  can  be  observed — redness  of  the  skin 
and  fluctuation  indicating  the  presence  of  pus.  When  the  outer  layers 
of  bone  are  first  affected  these  symptoms  occur  earlier.  In  either  case 
delay  in  treatment  is  disastrous,  for  hour  by  hour  the  periosteum  is 
being  separated  from  the  bone,  and  with  it  the  nutrition  of  the  osseous 
tissue  is  cut  off  Necrosis  is  the  inevitable  result.  The  neighboring 
joint  is  in  imminent  danger,  for,  sooner  or  later,  the  inflammatory 
process  will  extend  to  it,  distending  the  capsule  with  effused  fluid,  into 
which  pyogenic  organisms  may  be  brought  through  the  blood-vessels 
or  lymphatics. 

After  the  formation  of  pus  and  its  evacuation  through  a  natural 
opening  or  by  incision  an  exploration  can  be  made  with  a  probe. 
When  healthy  bone  is  touched  the  probe  produces  a  dull  sound  and 
the  periosteum  gives  a  firm  and  roughened  sensation.  Carious  bone  is 
gritty,  and  the  probe  can  be  easily  driven  into  it.  Necrosed  bone  gives 
a  clear,  high-pitched  note,  is  usually  smooth,  and,  if  separated,  the 
diseased  portion  is  movable. 

Treatment. — There  are  few  diseased  conditions  in  which  delay  in 
treatment  is  so  dangerous  as  here.  Fomentations,  iodin,  cold  appli- 
cations, and  medication  are  delusive  and  a  waste  of  valuable  time. 
These  are  cases  in  which  symptoms  should  not  be  treated.  The  pain 
may  be  the  leading  symptom,  and  in  an  unguarded  moment  you  may 
give  a  hypodermic  injection  of  morphin.  The  patient  feels  better  for 
a  time,  but  the  destructive  process  is  still  going  on.  A  high  tempera- 
ture may  induce  you  to  give  one  of  the  coal-tar  derivatives,  such  as 
acetanilid.  This  also  is  a  mistake.  A  profuse  perspiration,  with  a  fall 
of  temperature,  may  follow,  but  the  security  is  such  as  the  ostrich  finds 
when  he  hides  his  head  in  the  sand. 

The  only  treatment  that  can  prove  of  any  avail  must  be  radical. 
The  bone  must  be  cut  down  upon,  drilled,  or  trephined,  and  a  free  exit 
given  to  the  pent-up  products  of  inflammation.  Tension  once  relieved, 
pain  will  soon  cease.  Evacuate  the  pus,  scrape  out  the  bone-cavity, 
irrigate  with  corrosive-sublimate  solution  to  destroy  remaining  germs, 
and  pack  with  iodoform  gauze.  The  temperature  will  speedily  fall. 
When  the  medulla  is  extensively  diseased  it  is  well  to  trephine  at  two 
or  more  points  and  scrape  out  the  intervening  tissue.  It  is  better  to 
take  too  much  than  too  little,  and  the  whole  medullary  canal  of  a  long 
bone,  such  as  the  tibia,  is  often  removed  with  advantage. 

The  after-treatment  consists  in  keeping  the  limb  at  rest  on  a  suitable 
splint,  securing  perfect  drainage,  and  guarding  against  sepsis.  The 
constitutional  and  hygienic  treatment  consists  in  nourishing  diet,  cod- 
liver  oil,  quinin,  and  fresh  air. 

Necrosis. — One  of  the  objects  of  early  and  radical  treatment  of 


INJURIES  AND  DISEASES   OF  THE    OSSEOUS  SYSTEM.  93 

the  inflammatory  process  in  bone  is  the  prevention  of  necrosis.  The 
stripping  off  of  the  periosteum,  or  the  pressure  produced  by  hyperemia 
and  the  other  processes  in  the  Haversian  canals  or  the  medulla,  cuts 
off  the  blood-supply  to  a  greater  or  less  area  of  bone.  This  portion  dies, 
and  the  process  is  called  necrosis.  It  is  gangrene  of  bone.  Two  or 
three  months  usually  elapse  before  the  dead  portion  of  bone  becomes 
detached.  During  this  time  profuse  suppuration  is  taking  place,  which 
is  a  great  tax  upon  the  patient's  strength.  As  soon,  therefore,  as  the 
dead  bone  has  become  detached,  or  even  before  in  certain  cases,  no 
time  should  be  lost  in  removing  it.  The  necrosed  piece  of  bone  is 
called  a  seqiicstnun,  which  simply  means  that  it  is  separated  from  the 
sound  portion.  If  the  process  is  long  delayed  and  nature  has  had 
time  to  make  attempts  at  repair,  more  or  less  new  bone  is  thrown  out. 
This  is  especially  the  case  when  the  periosteum  and  the  outer  layers 
of  bone  remain  healthy.  The  new  bone  forms  an  osseous  envelope 
around  the  sequestrum,  and  to  this  envelope  the  name  involiicniui  is 
given.  It  is  often  found  to  be  pierced  by  one  or  more  openings,  due 
to  ulceration  through  the  periosteum  and  bone-layers  outside  the 
sequestrum.  These  openings  are  called  cloaca.  In  removing  dead 
bone  these  are  important.  Through  a  cloaca  we  can  pass  a  probe 
or  finger  and  determine  the  existence  of  a  sequestrum,  and  by  cut- 
ting away  a  sufficient  area  of  the  involucrum  we  can  remove  the 
sequestrum. 

ScquestrotojHv,  or  the  operation  for  the  removal  of  necrosed  bone,  is 
performed  as  follows  :  When  the  bone  to  be  removed  is  in  one  of  the 
extremities,  the  limb  should  be  elevated  for  four  or  five  minutes  and  a 
rubber  bandage  applied  on  the  proximal  side  of  the  disease.  Should 
the  sequestrum  present  at  one  of  the  cloacje  and  be  of  small  size,  it  may 
be  grasped  by  forceps  and  pulled  away.  In  most  cases  a  free  opening 
will  have  to  be  made  by  first  cutting  through  the  soft  parts  and  then 
chiselling  away  the  involucrum.  The  sequestrum  can  then  be  taken 
away  as  a  whole  or  in  pieces.  The  next  procedure  will  be  to  scrape 
away  the  granulation  tissue  which  lines  the  cavity.  The  parts  are 
well  irrigated  and  packed  with  iodoform  gauze,  which  must  be  changed 
about  twice  a  week,  or  more  frequently  if  there  is  much  discharge. 

Chronic  Inflammation  of  Bone. — Cases  of  chronic  inflam- 
mation are  for  the  most  part  tubercular,  pyogenic,  syphilitic,  or 
malignant,  and  follow  a  chronic  course  from  the  beginning. 

Chronic  suppurative  osteomyelitis  may  occur  as  a  primary  affection 
or  it  may  take  place  at  the  site  of  a  former  acute  attack.  It  has  a 
decided  preference  for  the  long  bones,  and  its  victims  are  generally 
children  and  adolescents.  The  cancellous  tissue  near  the  extremities 
of  the  femur  and  the  tibia  is  often  the  starting-point.  The  disease  is 
generally  circumscribed,  and  has  a  tendency  to  produce  two  opposite 
conditions,  one  being  abscess  and  the  other  overgrowth.  Abscess  is 
liable  to  form  in  the  interior  of  the  bone,  and  especially  in  the  lower 
end  of  the  femur  and  either  end  of  the  tibia.  Overgrowth  is  due  to 
the  constant  irritation  which  chronic  inflammation  produces.  The 
increase  in  the  growth  may  be  considerable,  and  is  sometimes  sufficient 
to  cause  deformity.  In  tubercular  cases  the  bone  may  be  lengthened, 
but  shortening  and  atrophy  are  more  common. 


94  SCRGICAI.    DIAGNOSIS  AND    TREATMENT. 

Syjuptoiiis. — I'ain  is  the  most  prominent  symptom.  It  is  of  a  gnaw- 
ing or  boring  character  and  often  very  severe.  There  is  always 
increased  pain  on  pressure  over  a  Hmited  area,  and  this  sign  is  of  great 
value  in  forming  a  diagnosis.  The  pain  is  worse  at  night.  It  may 
disappear  at  times,  giving  the  patient  a  respite  for  days,  weeks,  or  even 
months,  to  return  again  with  its  former  severity.  If  you  grasp  the 
bone,  it  will  be  found  to  be  enlarged. 

Trcatmoit. — When  a  case  presents  the  characters  above  described 
there  is  only  one  thing  to  be  done,  and  that  is  to  get  rid  of  the  pus 
which  is  confined  and  secure  drainage  from  the  diseased  area.  In  my 
collection  of  specimens  I  have  a  small  piece  of  bone  removed  by 
trephine  from  the  lower  end  of  the  tibia  of  a  boy  fourteen  years  of  age. 
The  portion  of  bone  removed  contained  a  small  abscess  large  enough 
to  admit  the  end  of  the  little  finger,  and  this  comprised  the  whole  of 
the  diseased  area.     Recovery  was  rapid. 

When  the  tender  point  is  found  an  incision  should  be  made  over  it 
down  to  the  bone.  The  periosteum  having  been  separated  by  an 
elevator,  the  bone  can  be  explored  by  a  fine  drill  at  different  points. 
If  pus  is  found,  or  even  a  suspicion  of  it,  a  trephine  is  applied  and  a 
piece  removed,  going  well  into  the  center  of  the  bone.  Should  there 
still  be  no  appearance  of  an  abscess,  the  drill  may  be  used  to  penetrate 
the  walls  of  the  trephined  cavity.  When  pus  is  reached,  a  free  exit 
must  be  given  to  it,  and  all  the  diseased  part  scraped  away  with  a 
Volkmann's  spoon.  After  thorough  irrigation  with  i  :  2000  solution  of 
corrosive  sublimate  the  cavity  is  packed  with  iodoform  gauze  and  an 
antiseptic  dressing  applied.  Even  if  no  pus  be  found  after  cutting 
into  the  bone,  benefit  will  result,  for,  tension  having  been  relieved, 
the  terrible  gnawing  or  boring  pain  will  cease.  If  the  operation  be 
done  with  proper  antiseptic  care,  it  will  do  no  possible  harm.  Better 
that  a  mistake  be  made  by  trephining  a  healthy  bone  than  that  a  dis- 
eased bone  should  go  unrelieved.     In  case  of  doubt,  trephine. 

Tubercular  Ostitis. — The  favorite  situations  of  this  form  of 
disease  are  the  bones  adjacent  to  the  hip-,  the  knee-,  and  the  elbow- 
joints,  and  also  the  bones  of  the  wrist  and  ankle.  The  progress  of 
the  disease  is  ordinarily  slow,  and  in  its  early  stages  very  insidious. 
The  pain  is  often  spoken  of  as  "  starting  "  in  character.  In  some  cases 
it  is  so  light  as  to  be  scarcely  noticed,  but  pressure  always  reveals  its 
existence.  The  early  symptoms  may  be  little  more  than  an  impair- 
ment in  the  movements  of  the  limb  with  rigidity  of  the  muscles  of  the 
neighboring  joint.  Local  elevation  of  temperature  may  be  observed. 
Tubercular  inflammation  tends  to  the  formation  of  fluid  in  the  part 
affected.  This  collection  is  sometimes  erroneously  spoken  of  as  an 
abscess.  It  contains  vast  numbers  of  the  tubercle  bacilli,  but  the 
micro-organisms  of  pus  are  wanting.  Should  such  a  cavity  be  laid 
open  without  antiseptic  precautions  and  pus-germs  find  entrance,  a 
double  infection  will  be  the  result,  and  the  most  serious  consequences 
are  liable  to  follow.  This  is  why  the  older  surgeons  found  it  so  dis- 
astrous to  open  tubercular  joints  or  psoas  abscesses. 

The  symptoms  that  distinguish  tubercular  from  other  inflammations 
of  bone  are — 

I.  Atrophy  of  the  muscles.     The  parts  both  above  and  below  the 


INJURIES  AND  DISEASES   OF  THE    OSSEOUS  SYSTEM.  95 

seat  of  disease  become  wasted  to  such  a  degree  that  simple  disuse  is 
not  sufficient  to  account  for  it. 

2.  Spasm  of  the  muscles.  This  is  generally  observed  when  the 
patient  is  dropping  off  to  sleep.  The  muscles  acquire  a  persistent 
rigidity  which  is  very  noticeable  in  the  early  stages  of  spinal  caries 
and  in  hip-joint  disease.  Flexion  of  joints  is  almost  sure  to  occur, 
the  flexor  muscles  gradually  overcoming  the  extensors  until  serious 
deformity  results. 

Treatment. — Tuberculosis  is  greatly  influenced  by  keeping  the  part 
at  rest,  and  if  adopted  in  the  early  stage  of  the  disease  immobilization 
may  be  sufficient  to  produce  arrest  of  the  tuberculous  process.  Con- 
finement to  bed,  plaster-of- Paris  dressings,  and  suitable  splints  will  fulfil 
this  indication.  The  general  principles  of  treatment  in  tuberculosis  will 
also  need  to  be  kept  in  view,  such  as  good  hygienic  conditions,  nour- 
ishing food,  and  remedies  directed  to  the  improvement  of  the  patient's 
strength.  Some  excellent  results  have  been  obtained  by  local  injec- 
tions of  iodoform,  of  chlorid  of  zinc,  or  of  acid  phosphate  of  lime.  Clin- 
ical experience  has  shown  that  in  most  cases  where  arrest  of  the  tuber- 
culous process  has  taken  place  the  bacilli  have  been  encapsulated  by 
infiltration  of  the  healthy  tissue  surrounding  them.  They  have  been, 
as  it  were,  enclosed  by  a  wall  which  they  cannot  break  through.  The 
object  of  the  injections  above  mentioned  is  to  produce  this  condition, 
and  at  the  same  time  to  destroy  the  vitality  of  the  bacilli.  Iodoform  is 
probably  the  least  irritating  and  the  most  satisfactory  of  this  class  of 
remedies.  It  can  be  used  in  a  solution  containing  one  part  of  iodo- 
form and  ten  of  glycerin.  By  means  of  a  needle  long  enough  to  reach 
the  diseased  area  this  fluid  is  injected  in  small  quantity  every  three, 
seven,  or  ten  days. 

A  method  of  treatment  has  been  recommended  by  Bier  which  is 
worth  consideration.  Clinical  evidence  having  shown  that  tubercles  do 
not  multiply  in  parts  supplied  by  too  much  blood,  an  artificial  chronic 
congestion  is  secured  by  wearing  an  elastic  bandage  above  the  seat  of 
the  disease.  This  bandage  is  applied  at  more  and  more  frequent  inter- 
vals, and  as  tightly  as  the  patient  can  bear  it,  until  at  last  he  is  able  to 
wear  it  almost  constantly. 

When  the  above  methods  are  unsuitable,  or  in  cases  where  they 
have  failed,  an  operation  should  be  resorted  to  for  the  removal  of  the 
diseased  area.  Scraping  and  removal  of  the  infected  tissues  must  be 
more  thorough  here  than  in  pyogenic  ostitis.  The  walls  of  every  sinus, 
the  medulla  of  infected  bone,  and  every  suspected  deposit  of  tubercle 
in  the  soft  parts,  such  as  the  skin,  tendon-sheaths,  or  synovial  cavities, 
must  be  thoroughly  scraped.  When  the  disease  extends  into  a  joint  the 
question  of  resection  or  amputation  will  have  to  be  considered. 

Syphilitic  Diseases  of  Bone.— The  bones  most  liable  to  this 
form  of  ostitis  are  the  long  bones  and  those  of  the  skull  and  the  face. 
The  frontal  is  the  one  most  frequently  affected  of  all  the  bones.  Pain, 
worse  at  night,  is  an  early  symptom,  and  may  even  appear  before  the 
eruption  on  the  skin.  At  first  it  has  the  character  of  a  periostitis,  but 
later  smooth,  firm,  flat  elevations  about  one  or  two  centimeters  in 
diameter  can  be  felt ;  these  are  tender  on  pressure.  They  yield  readily 
to  treatment,  but  run  on  for  an  indefinite  period  if  let  alone.     lodid  of 


96 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


potassium  and  the  mercurials  act  as  specifics.  No  operative  inter- 
ference is  required. 

Fragilitas  Ossium. — An  abnormal  brittleness  of  the  bones  by 
which  they  are  liable  to  fracture  on  the  slightest  cause  is  known  as 
fragilitas  ossium.  This  condition  may  be  congenital,  the  bones  even  in 
utero  being  fractured,  and  the  fragility  continuing  until  mature  life, 
when  it  may  cease.  The  disease  may  also  be  the  result  of  debilitating 
conditions  which  compel  long  confinement  to  bed.  Other  causes  are 
syphilis,  malignant  tumors,  the  early  stage  of  rachitis,  general  paralysis, 
and  tabes. 

Treatment. — Nothing  can  be  done  further  than  to  guard  against 
accident  and  to  treat  the  fracture  in  the  ordinary  manner. 

Rachitis. — Rachitis,  or  rickets,  is  a  disease  of  infancy  and  childhood 
having  as  its  leading  features  a  deficiency  of  lime  salts  in  the  bony 
framework  and  absorption  of  bone  already  formed.  It  is  generally 
seen  among  the  poor  in  crowded,  unhealthy  portions  of  cities,  where 


Fig.  33.- 


-Rachitic  curvature  before  operation.       FiG.  34. — Rachitic  curvature  after  operation. 
(From  photographs  in  the  collection  of  Dr.  T.  S.  Roberts.) 


ventilation  is  bad  and  the  general  surroundings  are  unhealthful.  It 
begins  about  the  first  or  second  year  of  life,  rarely  after  the  sixth.  Its 
starting-point  is  the  epiphyseal  line,  where  there  is  found  a  deficiency 
of  lime  salts,  and  at  the  same  time  an  increased  growth  of  cartilage. 
Hence  the  bone  is  wider  and  thicker  at  this  part.  The  child  is  loose- 
jointed,  the  ligaments  being  relaxed,  and  movements  of  the  articulations 
frequently  cause  pain  (Figs.  33,  34).  When  the  spinal  column  is  the 
seat  of  the  disease  one  or  other  of  the  various  spinal  curvatures  may 
result.  Rachitic  children  are  often  hydrocephalic,  and  deformities  of 
the  brain  are  not  uncommon. 

Symptoms. — One  of  the  earliest  indications  of  rachitis  is  perspiration 
about  the  head,  particularly  during  sleep.  The  child  is  restless,  and 
rolls  his  head  from  side  to  side  on  the  pillow.     There  is  constipation ; 


INJURIES  AND  DISEASES   OF  THE    OSSEOUS  SYSTEM.  97 

the  urine  is  increased  in  quantity  and  loaded  with  phosphates.  Enlarge- 
ment of  the  epiphyseal  end  of  the  bones  will  be  most  likely  to  occur 
at  the  lower  end  of  the  radius  and  the  ribs.  The  forehead  and  the 
frontal  eminences  are  enlarged.  The  changes  in  the  ribs  produce  the 
characteristic  pigeon's  breast.  Teething  is  delayed.  The  anterior 
fontanelle  fails  to  unite,  and  the  want  of  growth  results  in  a  dwarfing 
of  stature.  Bronchitis,  catarrhal  affections,  and  pneumonia  are  common 
complications,  and,  in  some  instances,  causes  of  death.  About  90  per 
cent,  of  the  cases  improve  under  proper  management. 

Treatment. — The  treatment  of  this  affection  may  be  surnmed  up 
under  two  words — nutrition  and  hygiene.  Removal  from  crowded,  ill- 
ventilated  dwellings  to  the  pure  air  of  the  country,  sea-air,  and  sea- 
bathing are  invaluable.  Of  drugs,  the  best  are  cod-liver  oil,  syrup  of 
the  iodid  of  iron,  phosphorus,  and  the  lactophosphate  of  lime. 

Osteomalacia. — While  rickets  is  a  disease  of  childhood,  osteo- 
malacia, mollities  ostium,  or  malacosteon  is  a  disease  of  adult  life.  The 
most  frequent  subjects  are  pregnant  women  or  those  who  have  borne 
children.  In  men  it  is  rarely  found.  Its  cause  has  never  been  clearly 
explained.  Among  the  causes  assigned  are  defect  of  lactic  acid,  defec- 
tive nutrition,  ovarian  and  uterine  disorders,  and  changes  in  the  trophic 
nerves.  The  leading  feature  of  the  disease  is  a  progressive  softening 
of  the  bones,  resulting  in  all  sorts  of  deformities,  going  on  from  bad  to 
worse,  and  ending  in  death  from  exhaustion  or  from  some  complication, 
such  as  disease  of  the  lungs,  bronchi,  or  pleura. 

Symptoms. — Its  early  history  is  obscure.  Pain  is  one  of  the  most 
important  symptoms.  It  occurs  at  a  number  of  points  of  the  body, 
and  is  liable  to  be  mistaken  for  rheumatism.  The  sex  of  the  patient 
and  the  existence  of  pregnancy  with  large  deposits  of  phosphates  in 
the  urine  should  excite  suspicion.  When  osteomalacia  has  advanced 
so  far  as  to  cause  bending  and  deformities  of  the  bones,  no  doubt  can 
exist  of  the  terrible  character  of  the  malady. 

Treatment. — The  treatment  is  by  no  means  satisfactory.  Some  cases 
are  mild  and  have  a  tendency  to  remain  almost  stationary ;  others  pro- 
gress to  a  fatal  termination  in  spite  of  every  form  of  treatment.  The 
best  hygienic  surroundings  are  indispensable,  and  deformity  should  be 
prevented  by  the  use  of  protective  dressings.  Pregnancy  should  be 
avoided,  as  it  has  an  especially  injurious  effect  upon  the  disease.  The 
medical  treatment  consists  in  the  administration  of  cod-liver  oil,  phos- 
phates, and  lime  salts,  but  they  produce  little  if  any  benefit.  Removal 
of  the  ovaries  and  uterus  has  had  some  advocates,  and  a  few  cases 
have  been  reported  in  which  there  was  decided  benefit  from  the 
operation. 

Actinomycosis. — Until  recent  years  this  disease  was  confounded 
with  sarcoma,  owing  to  the  fact  that  its  microscopical  structure  bears  a 
close  resemblance  to  the  round-celled  variety  of  these  tumors.  It  is 
now  known  to  be  a  disease  due  to  a  specific  germ.  Infection  usually 
takes  place  through  the  mouth,  either  from  a  wound  or  a  carious  tooth. 
It  may  also  find  a  portal  of  entrance  by  way  of  the  lungs,  where, 
reaching  the  pulmonary  alveoli,  it  sets  up  a  broncho-pneumonia. 
The  chief  characteristic  of  the  disease  is  a  chronic  inflammation  which 
closely  resembles  that  caused  by  the  tubercle  bacillus. 
7 


98 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


Syniptcwis. — An  enlargement  of  the  lower  jaw  or  an  ill-defined 
swelling  in  the  submaxillary  region  or  a  nodule  of  the  skin  is  generally 
the  first  symptom.  The  progress  of  the  disease  is  slow,  but  steady. 
The  lymphatics  and  blood-vessels  are  not  involved  until  a  late  period. 
Pain  and  swelling  are  not  marked  until  suppuration  begins.  Then  the 
local  and  constitutional  symptoms  become  as  marked  as  they  are  in 
acute  cellulitis  or  in  diffuse  osteomyelitis.  As  the  disease  progresses 
secondary  deposits  take  place  with  caseous  nodules  and  abscesses,  no 
part  of  the  body  being  exempt.  To  the  naked  eye  there  is  nothing  to 
distinguish  the  growth  from  sarcoma  or  granulation  tissue.  The 
special  character  of  the  disease  must  be  settled  by  finding  the  micro- 
organisms which  produce  it. 

The  granulation  tissue  and  the  pus  contained  in  it  are  filled  with  round 
bodies  like  millet-seeds  of  a  yellow  color.  The  fungus  itself  is  easily 
recognized  by  its  star-hke  masses  of  mycelium. 

TiratJHcnt. — When  recognized  early  the  diseased  part  should  be 
thoroughly  removed,  and  when  this  can  be  done  the  prognosis  is 
favorable. 

Tumors  of  Bone. — The  benign  tumors  of  bone  are  exostoses, 
fibromata,  and  enchondromata ;  the  malignant  are  sarcomata  and 
carcinomata. 

Exostoses  are  localized  overgrowths   of  bone  (Fig.  35),  the  term 


Fig.  35. — Exostosis  of  head  of  the  tibia. 

hypertrophy  being  applied  when  the  whole  extent  of  the  bone  is 
increased  in  size.  Their  structure  is  the  same  as  bone  itself,  and  they 
are  divided  into  two  classes,  according  to  their  density,  the  ivory  or 
eburnated  and  the  cancellous.  The  ivory  variety  is  commonly  found 
on  fliat  bones,  and  a  favorite  position  is  the  frontal  sinus,  where  it  may 
grow  to  considerable  size,  resulting  in  horrible  deformity.  This  form 
is  often  associated  with  syphilis.  The  cancellous  variety  affects  the 
long  bones.  Exostoses  are  often  hereditary,  and  in  that  case  are  gen- 
erally symmetrical  and  multiple.  They  begin  to  grow  in  childhood, 
and  their  starting-point  is  the  junction  of  the  shaft  with  its  epiphysis. 
They  grow  from  cartilage,  which  is  gradually  converted  into  cancellous 
tissue,  and  generally  cease  to  enlarge  when  the  bone  to  which  they  are 
attached  has  reached  its  full  development  (Fig.  36). 

Diagnosis  is  easy.     The  tumors  are  painless,  hard,  and  fixed,  closely 


INJURIES  AND  DISEASES   OF  THE    OSSEOUS  SYSTEM. 


99 


connected  with  bone,  and  can  be  readily  felt  or  seen.  Exostoses  give 
little  trouble,  except  under  the  following  conditions  ;  when  they  inter- 
fere with  the  free  use  of  a  joint,  especially  in  flexion  :  when  by  their 
pressure  they  cause  atrophy  or  ulceration  of  the  overlying  soft  parts ; 
or  when  they  occur  in  the  inner  surface  of  the  skull  and  press  upon  the 
brain.  Even  in  the  last-mentioned  condition  no  serious  cerebral  dis- 
turbance may  result,  and  the  existence  of  a  tumor  may  be  discovered 
only  after  death. 

Treatment. — Where   no   inconvenience   is   caused   no  treatment  is 


Fig.  36. — Osteoma  growing  on  the  under  surface  of  the  scapula  (from  a  photograph  in  the 
collection  of  Dr.  Graham,  Washington,  D.  C). 

called  for.  The  growth  can  be  bfoken  off  if  it  be  attached  to  the  bone 
by  a  narrow  pedicle,  but  in  most  cases  it  is  best  to  cut  down  upon  and 
remove  the  tumor. 

Chondromata,  or  Cartilaginous  Tumors. — These  growths  are 
found  chiefly  on  the  extremities  ot  the  long  bones  and  in  connection 
with  the  small  joints  of  the  hands  and  feet  (Fig.  37).  If  composed  of 
purely  cartilaginous  tissue,  they  are  benign,  but,  unfortunately,  they 
often  contain  a  mixture  of  sarcomatous  elements  which  places  them 
within  the  category  of  malignant  growths. 


lOO 


SURGICAL    DIAGNOSIS  AND    TREATMENT. 


Chondromata  occur  on  the  surface  or  in  the  center  of  bone,  in  the 
former  case  being  very  easy  of  diagnosis,  in  the  latter  exceedingly 
difficult.     They  have  a  tendency  to  become  cystic. 

Syjiiptojiis. — A  slowly-growing  tumor,  elastic  and  firm,  of  less  density 
than  bone  and  irregular  in  shape,  situated  at  the  extremity  of  a  long 
bone  or  at  the  small  joints  of  the  hands  or  feet,  is  suggestive  of  chon- 
droma. Pain  is  not  present  unless  a  nerve  be  pressed  upon,  which 
does  not  often  occur.     When  the  growth  is  central  it  cannot  be  diag- 


FlG.  37. — Lad  twenty  years  of  age  with  multiple  chondromata  (after  Steudel). 

nosed  until  it  has  attained  considerable  size,  and  even  then  its  nature 
often  remains  in  doubt  until  after  its  removal. 

Treatment. — The  only  effective  remedy  is  extirpation.  The  growth 
itself  may  be  removed  and  the  surrounding  parts  scraped  away,  or  it 
may  be  necessary  to  remove  a  part  or  a  whole  of  the  bone  to  which  it 
is  attached.     In  some  cases  nothing  short  of  amputation  will  suffice. 

Fibromata. — The  commonly  chosen  seats  of  fibromata  are  the  jaws 
and  the  base  of  the  skull.  The  growth  begins,  as  a  rule,  in  the  peri- 
osteum and  is  pedunculated.     Rare  cases  occur  in  which  the  starting- 


INJURIES  AND   DISEASES   OF   THE    OSSEOUS  SYSTEM.  lOI 

point  is  the  center  of  the  bone.  A  tumor  composed  purely  of  fibrous 
tissue  is  rare.  With  the  exception  of  epuhs  and  naso-pharyngeal  polypi, 
the  tumors  of  a  fibroid  character  are  fibro-sarcomata.  Fibromata  grow 
slowly,  have  a  tendency  to  become  cystic,  and  often  cease  to  enlarge 
when  the  bony  skeleton  has  arrived  at  maturity. 

Diagnosis. — Fibrous  tumors  are  irregular  in  shape,  firm  to  the  touch, 
but  not  so  hard  as  bone,  with  which  they  are,  as  a  rule,  connected. 
The  so-called  naso-pharyngeal  polyp  commencing  on  the  under  surface 
of  the  sphenoid  bone  fills  in  time  the  naso-pharynx,  the  posterior  nares, 
and  the  antrum.  These  growths  are  dangerous  on  account  of  their 
tendency  to  free  hemorrhage.  When  the  patient  reaches  the  age  of 
about  twenty-five  years  the  polyp  ceases  to  grow  and  atrophy  com- 


FlG.  38. — Osteosarcoma  of  femur  (from  a  photograph  in  the  collection  of  Dr.  jepson, 

Sioux  City,  Iowa). 


mences.  Unless  hemorrhage  is  frequent  and  copious  it  is  advisable  to 
delay  treatment  in  the  hope  that  this  favorable  change  may  take  place. 

Treatment. — Remove  either  by  extirpation  of  the  tumor  alone  or  by 
resection  of  the  portion  of  bone  from  which  the  growth  has  originated. 

Malignant  Tumors  of  Bone. — Carcinoma  of  bone  is  exceed- 
ingly rare,  and  is  always  secondary  or  due  to  simple  extension  of  the 
disease  from  neighboring  structures. 

Sarcomata,  on  the  other  hand,  are  common,  and  are  distinguished 
from  all  other  tumors  of  bone  by  the  rapidity  of  their  growth  (Fig.  38). 
No  bone  in  the  body  is  free  from  liability  to  this  form  of  malignant  dis- 
ease, but  certain  bones  are  especially  prone — viz.  the  lower  end  of  the 
femur  and  the  upper  end  of  the  tibia  ;  that  is  to  say,  the  bones  on  each 
side  of  the  knee-joint.      The  jaw  is  also  a  common  situation,  and  the 


I02 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


disease  here  constitutes  one  of  the  forms  of  epulis.  Injury,  such  as 
fracture  or  bruising  of  a  bone,  frequently  precedes  the  growth  and 
must  be  considered  an  exciting  cause.  Sarcomata  in  bone,  as  else- 
where, may  occur  at  any  age,  but  the  great  majority  of  cases  are  found 
in  early  life.     After  forty  years  of  age  the  disease  is  very  rare. 

If  we  classify  the  tumors  according  to  their  histological  structure, 
we  have  three  varieties — round-celled,  spindle-celled,  and  giant-celled. 
The  malignancy  exists  in  about  the  proportion  of  the  size  of  the  cell. 
The  round  cell  and  spindle  cell  are  found  in  tumors  of  the  most  rapid 
growth,  while  the  giant-celled  neoplasms  grow  slowly  and  have  fewer 
malignant  characters. 


Fig.  39. — Round-celled  sarcoma  (from  a  photograph  in  the  collection  of  Dr.  Graham, 
Washington,  D.  C). 


A  sarcoma  is  classed  among  malignant  growths  for  the  following 
reasons : 

(i)  It  infiltrates  the  surrounding  structures. 

(2)  The  lymphatic  glands  become  involved  sooner  or  later. 

(3)  It  occurs  in  the  form  of  secondary  deposits  in  other  parts,  the 
lung  being  specially  liable  to  this  metastasis. 

Clinically,  sarcomata  of  bone  may  be  divided  into  two  varieties, 
periosteal  and  central. 

Periosteal  Sarcomata. — These  are  the  most  malignant  of  bone- 
tumors,  being  composed,  as  a  rule,  of  round  or  spindle  cells  (Fig.  39). 
There  is  a  special  tendency  in  this  variety  to  affect  different  organs,  so 
that,  although  no  sign  of  the  disease  is  seen  in  the  stump  after  an 
amputation,  a  secondary  deposit  in  the  lung  may  carry  off  the  patient. 


IXJCRIES  AND   DISEASES   OF   THE    OSSEOUS  SYSTEM. 


lO- 


The  deeper,  more  vascular  layer  of  the  periosteum  is  the  starting-point. 
While  the  tumor  is  small  the  external  layer  of  the  periosteum  is  stretched 
over  it,  but  in  the  course  of  time  this 
gives  way,  the  growth  breaks  through, 
and  rapidly  infiltrates  the  surrounding 
tissues  (Fig.  40). 

Central  sarcomata  begin  at  the  ar- 
ticular ends  of  the  long  bones  or  in 
the  cancellous  tissue  of  the  short  ones. 
They  are  not  so  malignant  as  the  peri- 
osteal variety,  and  in  the  early  stages 
are  not  easily  recognized.  As  the 
tumor  increases  in  size  its  pressure 
produces  atrophy  of  the  bone,  until 
nothing  is  left  but  a  thin  shell  of 
osseous  tissue,  which  cracks  beneath 
the  fingers  like  an  egg-shell.  The 
fracture  of  this  weakened  bone  from 
some  trivial  cause  may  be  the  first 
thing  to  excite  suspicion  of  the  real 
nature  of  the  disease. 

Symptoms. — The  early  s)^mptoms 
of  sarcoma  are  frequently  obscure. 
Pain,  which  may  be  mistaken  for 
rheumatism,  is  generally  present.  It 
is  worse  at  night,  and  may  be  very 
severe.  In  many  cases  there  is  a  his- 
tory of  a  traumatism.  In  a  young 
person  a  rapidly-growing  tumor  at  the 
seat  of  a  newly-united  fracture  or  in 
one  of  the  bones  near  the  Jcnee-joint 
must  be  looked  upon  with  suspicion. 

The  following  questions  may  be  considered : 

{a)  Is  there  swelling  of  the  bone  ?  If  there  be  a  periosteal  sarcoma, 
a  distinct  swelling  will  be  felt,  usually  along  one  side  of  the  bone,  fusi- 
form in  shape,  and  avoiding  the  extremity  of  the  bone.  The  swelling, 
in  the  central  variety,  appears  at  a  much  later  period,  is  more  globular 
in  shape,  and  has  egg-shell  crackling  when  pressed  upon  by  the  fingers. 
It  is  found  at  the  cancellous  end  of  the  bone. 

ip)  Does  the  tumor  pulsate  ?  Pulsation  is  a  character  of  the  central 
variety,  and  of  the  periosteal  when  connected  with  the  flat  bones.  This 
pulsation  is  readily  distinguished  from  the  expansile,  heaving  pulsation 
of  an  aneurysm.  Even  should  a  thrill  and  bruit  be  present,  they  are 
only  observed  over  small  portions  of  the  tumor.  Pressure  has  little  or 
no  effect  upon  the  size  of  the  swelling,  and  pulsation  in  the  arter>^  below 
is  not  impaired,  except  when  the  growth  compresses  the  main  vessel 
against  the  bone. 

The  consistence  of  the  tumor  is  subject  to  great  variety.  Sometimes 
it  is  hard  and  dense,  at  other  times  soft  and  fluctuating.  Should  spon- 
taneous fracture  occur,  followed  by  a  tumor  of  rapid  growth,  a  diag- 
nosis of  central  sarcoma  could  be  made  with  confidence. 


Fig.  40. — Recurring  sarcoma  of  the 
humerus  (from  a  photograph  in  the 
collection  of  Dr.  Strickler,  New  Ulm, 
Minn.). 


104 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


In  any  case  of  doubt  an  exploring  needle  of  moderate  size  can  be 
thrust  into  the  growth.  If  it  be  a  sarcoma,  the  needle  will  be  found  to 
penetrate  the  bone,  and  through  the  cannula  may  escape  myeloid  cells 
or  other  elements  which  can  be  examined  microscopically. 

Diagnosis. — The  conditions  likely  to  cause  errors  in  diagnosis  are — 

1.  Chronic  inflammation  of  bone  with  necrosis.  Cases  of  this  kind 
are  exceedingly  puzzling,  and  no  amount  of  care  will  ensure  against  a 
mistaken  diagnosis.  When  the  course  of  ostitis  is  very  slow  and  free 
from  pain,  when  there  is  much  inflammatory  thickening  without  the 
formation  of  abscess,  and  the  sequestrum  has  formed  in  the  manner 
known  as  "  slow  necrosis,"  the  nature  of  the  disease  can  in  some 
instances  be  settled  only  by  free  exploration.  I  have  known  two  cases 
in  which  all  treatment  was  abandoned  and  a  diagnosis  of  sarcoma  made, 
which  afterward  proved  to  be  necrosis  of  the  femur  near  the  hip-joint. 

2.  Inflammation  in  a  neighboring  joint  may  mask  the  symptoms  of 
a  sarcoma  which  has  its  seat  in  the  cancellous  extremity  of  a  long 


\ 

\ 

t 

Fig.  41. — Acromegaly  (from  a  photograph  in  the  collection  of  Dr.  T.  P.  Findley). 

bone.  If  care  be  taken  to  look  for  all  the  characteristics  of  joint- 
disease,  mistakes  are  not  likely  to  happen.  The  position  of  the  limb, 
the  pain  (worse  at  night),  and  the  effusion  of  fluid  into  the  joint  are 
very  expressive,  while  the  history  of  a  tumor  in  the  bone,  beginning 
not  at,  but  near,  the  joint,  is  indicative  of  sarcoma. 

3.  Syphilitic  gummata.  The  difficulty  in  this  case  can  be  removed 
by  putting  the  patient  upon  iodid  of  potassium  for  a  few  days.  If  the 
growth  be  syphilitic,  it  will  steadily  diminish. 

4.  Aneurysm  of  bone.  This  condition,  if  it  ever  occur,  must  be 
exceedingly  rare. 

Tr^eatnient. — In  either  form  of  the  disease  the  only  chance  of  success 
lies  in  early  and  complete  removal.     If  the  tumor  is  situated  on  an 


INJURIES  AND  DISEASES  OF  MUSCLES,  TENDONS,  AND  BURSM.    105 

extremity,  amputation  affords  the  only  hope.  The  operation  should  be 
at  or  above  the  nearest  joint. 

In  periosteal  sarcoma  of  the  femur  amputation  at  the  hip-joint  is 
justifiable,  but  when  the  tumor  involves  the  middle  or  upper  third  of 
the  bone  the  case  is  practically  hopeless.  Recurrence  of  the  disease 
will  take  place,  either  in  the  stump  or  in  some  internal  organ,  notably 
the  lung. 

Acrotnegaly. — This  disease,  first  described  by  Marie  in  1886,  is 
attended  with  a  remarkable  enlargement  of  the  bones  of  the  face,  head, 
pelvis,  thorax,  feet,  and  hands  (Fig.  41).  Although  the  affection  is  of 
a  nervous  origin,  the  bony  enlargement  is  a  true  hypertrophy,  and  first 
appears  in  the  hands,  feet,  and  lower  jaw.  The  disease  is  generally 
symmetrical.  There  is  usually  freedom  from  pain  ;  the  joints  do  not 
become  ankylosed ;  it  follows  a  very  long  chronic  course,  and  up  to 
the  present  time  no  treatment  has  been  found  which  has  any  effect 
upon  the  disease. 


CHAPTER    IV. 

INJURIES   AND   DISEASES  OF   MUSCLES,  TENDONS,  AND 

BURS/E. 

The  injuries  to  which  muscles  are  liable  are  bruises,  strains,  ruptures, 
and  wounds. 

A  blow,  a  violent  and  prolonged  contraction,  or  overuse  will  result 
in  a  condition  known  as  a  strain.  The  muscle  is  tender  to  pressure ; 
there  is  more  or  less  swelling,  stiffness,  weakness,  and  pain,  especially 
when  the  muscle  is  brought  into  action.  The  injury  is  found  in  groups 
of  muscles,  such  as  the  deltoid,  the  pectorals,  biceps,  and  pronator 
radii  teres  (the  "  lawn-tennis  arm  ").  The  adductor  muscles  of  the 
thigh  are  affected  in  prolonged  and  severe  horseback-riding.  Any 
muscular  exertion  to  which  the  individual  is  unaccustomed  will  produce 
it.  A  blacksmith  can  swing  his  hammer  all  day  and  feel  no  ill  effects, 
but  a  man  unused  to  such  labor  will  find,  after  the  first  day's  toil,  that 
his  arm  is  powerless. 

Treatment. — Rest  and  hot  bathing  or  fomentations. 

Rupture. — Under  a  violent  muscular  effort  or  as  the  result  of  a 
severe  blow  the  muscular  structure  may  be  ruptured.  A  few  fibers 
may  give  way  or  the  whole  tnuscle  may  part  in  its  continuity.  The 
patient  experiences  a  sudden  and  severe  pain,  perhaps  attended  with  an 
audible  snap,  and  immediately  finds  that  the  muscle  has  lost  its  power 
in  whole  or  in  part.  On  examination  there  will  be  found  a  depression 
or  gap  at  the  seat  of  rupture,  and  swelling  due  to  extravasated  blood. 
Sometimes  the  quantity  of  blood  is  so  great  as  to  produce  a  hematoma. 
At  a  later  period  there  is  discoloration  of  the  skin.  The  function  of 
the  muscle  is,  of  course,  impaired  or  even  lost,  and  this  may  result  in 
permanent  weakness  of  the  limb.  In  debilitated  conditions  of  the  body, 
as  in  convalescence  from  typhoid  fever,  the  muscles  may  suffer  laceration 
from  trivial  causes,  owing  to  their  fibers  having  undergone  granular 
degeneration. 


I06  Sl'RGICAL   DIAGNOSIS  AND    TREATMENT. 

Treatment. — The  most  important  point  in  treatment  is  rest  in  the 
position  which  most  relaxes  the  ruptured  muscle.  The  torn  ends  may- 
be approximated  by  properly  applied  compression.  In  cases  of  com- 
plete separation  in  healthy  muscle  sutures  should  be  employed.  In 
diseased  muscle  this  is  useless,  as  the  stitches  will  tear  out.  Union  is 
effected  by  the  interposition  of  connective  tissue,  the  length  of  the 
band  depending  upon  the  degree  of  separation. 

Wounds. — By  accident  or  in  the  course  of  an  operation  wounds 
of  muscle  may  be  made,  and  are  subcutaneous  or  open.  The  symp- 
toms are  retraction  of  the  divided  ends  and  hemorrhage. 

The  treatment  consists  in  early  and  accurate  approximation  by  cat- 
gut sutures.     The  union  is  commonly  by  fibrous  tissue. 

Myalgia. — Pain  in  a  muscle  or  group  of  muscles  is  a  common 
ailment  depending  upon  overuse,  exposure  to  cold,  and  to  a  variety  of 
causes,  such  as  lead-poisoning  or  syphilis. 

The  diagnosis  of  pain  in  a  muscle  or  group  of  muscles  is  important. 
If  a  patient  complains  of  pain  over  the  deltoid,  for  example,  and  the 
pain  is  increased  when  he  raises  the  arm  from  the  side  of  his  own  voli- 
tion, while  no  pain  is  felt  if  the  surgeon  moves  the  arm  and  at  the  same 
time  the  muscles  are  kept  relaxed,  it  will  prove  that  the  muscle  is  the 
seat  of  pain.  Placing  the  limb  in  such  a  position  that  the  muscles  are 
stretched  will  also  produce  pain.  Hence  we  have  this  rule :  When  a 
muscle  is  affected  active  movement  produces  pain,  passive  movement 
is  painless  ;  over-extension  or  passive  stretching  is  painful.  Ligament- 
ous pain  is  elicited  by  any  movement,  either  active  or  passive,  that 
stretches  the  ligaments.  A  certain  amount  of  passive  motion  can  take 
place  in  a  joint  without  stretching  either  muscles  or  ligaments,  and  this 
amount  is  unattended  with  pain.  If  you  continue  this  movement  and 
pain  is  then  felt,  it  may  be  set  down  as  having  its  seat  in  the  ligaments. 

The  treatment  is  heat,  electricity,  massage,  and  sedative  applications. 

Myositis  (inflammation  of  muscle)  follows  an  injury,  but,  as  a  rule, 
this  is  unimportant  compared  to  the  effect  upon  other  tissues.  Muscular 
rheumatism,  so  called,  is  a  form  of  myositis,  and  is  often  produced  by  ex- 
posure to  cold.  Gonorrhea  is  often  attended  by  muscular  pains  (one  of  the 
forms  of  gonorrheal  rheumatism),  and  may  also  be  regarded  as  myositis. 

A  chronic  form  of  myositis  is  often  observed  in  syphilis.  It  gives 
a  wood-like  hardness  to  the  parts,  and  a  common  situation  is  the 
sphincter  ani  muscle. 

Symptoms. — The  symptoms  of  mj^ositis  are  stiffness  of  the  affected 
limb  and  pain,  which  is  worse  at  night  and  increased  whenever  the 
affected  muscles  are  brought  into  action.  Constitutional  symptoms, 
such  as  fever,  chills,  etc.,  are  seldom  present. 

Suppurative  myositis  is  by  no  means  common,  except  in  the  case 
of  the  psoas  muscle.  It  has  been  observed  as  a  localized  inflammation, 
resulting-  in  muscular  abscess  and  due  to  some  local  irritation,  such  as 
a  foreign  body  or  traumatism.  Diffuse  suppuration  m  muscles  has,  m 
a  few  instances,  been  observed.  It  appears  to  occur  under  the  same 
conditions  as  diffuse  osteomyelitis.  The  entrance  of  pyogenic- organ- 
isms is  by  a  wound  or  through  one  of  the  mucous  surfaces. 

Still  more  rare  is  the  disease  known  as  acute  progressive  myositis, 
which  involves  the  whole  of  the  muscular  system  and  ends  in  death  by 


INJURIES  AND  DISEASES  OE  MUSCLES,  TENDONS,  AND  BURS.E.     lO/ 

asphyxia  or  pneumonia.     It  is  probably  due  to  bacteria  the  nature  of 
which  has  yet  to  be  determined. 

Myositis    ossificans  (Figs.  42,  43)  is   a   pecuHar  form  of   muscle- 


FlG.  42. — Myositis  ossificans,  showing  the  ab- 
duction of  the  arms  (Stephen  Paget). 


Fig.  43. — Myositis  ossificans,  showing  the 
contraction  of  the  left  sterno-mastoid,  the 
masses  of  bone  in  the  latissimi  dorsi,  and 
the  extreme  amount  of  abduction  of  the 
arms  obtainable  (Stephen  Paget). 


The 


inflammation  in  which  bony  plates  form  in  the    muscular  tissues, 
most  common  situation  is  the  dorsal  region. 

Permanent  Shortening-  of  Muscle,  or  Contracture. — Long-con- 
tinued inactivity  of  muscles,  as  in  the  bed-ridden,  is  liable  to  result  in 
contracture.  These  cases  are  generally  of  a  mild  character,  and  the 
muscles  rapidly  regain  their  normal  condition  under  proper  exercise. 
Chronic  inflammation  of  the  muscle  itself,  descending  neuritis,  and 
sclerosis  following  lesions  of  the  cortex  produce  the  most  serious 
forms  of  permanent  shortening. 

Trcatvient. — In  the  milder  forms  massage  and  passive  motion  usually 
suffice.  In  the  severer  cases  tenotomy  may  be  required.  If  the  division 
of  a  tendon  is  likely  to  result  in  too  wide  a  gap,  the  tendon  can  be 
lengthened,  as  recommended  by  Anderson  (Fig.  44),  by  first  splitting  it 
in  the  middle  line,  and  then  sliding  the  ends 
to  the  proper  position  and  suturing  them. 

Tenosynovitis,  inflammation  of  ten- 
don or  thecitis,  is  a  common  affection.  A 
favorite  situation  is  at  the  wrist,  due  to 
over-exertion  of  the  flexor  tendons  in 
workmen,  such  as  stone-cutters  and  others, 
who  use  a  hammer  or  other  tool  con- 
tinuously. Any  tendon,  however,  may  be 
affected.  The  disease  occurs  in  three 
forms — acute,  suppurativ^e,  and  chronic. 

The  acute  form  is  due,  as  a  rule,  to 
overwork.  The  course  of  the  tendons  is 
sensitive  to  pressure,  and  the  overlying  skin  is  hot  and  in  some  cases 


B— , 


L 


1 


Fig.   44. — Anderson's    method    of 
lengthening  a  tendon. 


I08  SURGICAL   D/.  I  GNOSIS  AND    TREATMENT. 

reddened.  I^vcry  movement  of  tlie  muscle  is  attended  with  pain.  The 
surfaces  of  the  tendon  and  its  sheath  become  rou<;hened,  and  produce 
a  crepitant  sound  which  has  been  compared  to  the  rustUng  of  silk.  In 
aggravated  cases  the  exudation  not  only  involves  the  tendon-sheath, 
but  the  adjoining  cellular  tissue,  so  that  the  swelling  may  extend  from 
the  wrist  down  over  the  dorsum  of  the  hand  and  up  the  arm  to  or 
beyond  the  elbow.  Instead  of  simple  serous  fluid,  the  exudation  may 
contain  blood,  and  the  pain,  heat,  and  tension  may  be  excessive.  This 
variety  may  run  into  the  chronic  or  the  suppurative  form  of  the  disease. 

Chronic  tenosynovitis  is  nearly  always  of  tubercular  origin.  The 
tendons  of  the  forearm  are  those  most  commonly  involved.  The  prog- 
ress is  slow  and  is  attended  with  the  formation  of  granulation  tissue, 
in  which  can  be  found  the  tubercle  bacilli  in  large  numbers.  Accord- 
ing to  the  density  of  this  granulation  tissue  will  be  observed  swelling 
along  the  tendons,  firm  or  fluctuating.  In  some  cases  small  bodies 
resembling  rice  or  melon-seeds  are  formed  in  the  sac,  either  floating  in 
the  fluid  or  attached  to  the  walls. 

Besides  cases  due  to  tuberculosis,  chronic  tenosynovitis  is  frequently 
a  result  of  the  acute  form  of  the  disease.  This  may  be  due  to  some 
constitutional  dyscrasia,  such  as  gout  or  rheumatism,  or  it  may  be  a 
consequence  of  adhesions.  Long-continued  disease  of  a  limb  after 
fracture  or  other  injury  is  liable  to  result  in  such  adhesions,  which,  if 
not  completely  broken  up  by  passive  movements,  are  a  constant  source 
of  pain  and  inconvenience. 

Suppurative  Tenosynovitis. — This  is  most  frequently  met  with  in 
the  form  of  thecal  abscess  or  whitlow  in  connection  with  the  flexor 
tendons  of  the  fingers  or  thumbs.  It  was  formerly  not  uncommon  as 
a  result  of  septic  infection  after  amputations,  and  also  as  playing  a 
part  in  pyemia  and  septicemia.  Whitlow  begins  generally  as  the  result 
of  a  slight  injury  or  wound  which  admits  septic  organisms.  Having 
once  gained  an  entrance,  the  germs  follow  the  course  of  the  lymphatics, 
which  in  these  situations  is  toward  the  tendon-sheath,  the  periosteum, 
and  the  bone.  The  dense,  resisting  structure  of  the  sheath  and  its 
tendon  gives  no  room  for  expansion,  and  hence  the  intolerable  pain 
and  throbbing  which  characterize  whitlow.  Two  varieties  of  whitlow 
are  recognized — the  superficial  and  the  deep.  The  superficial  variety 
occurs  about  the  nails  and  affects  one  or  several  fingers  at  the  same 
time.  The  subjects  of  the  disease  are  delicate  children  or  debilitated 
persons.  In  some  instances  it  runs  its  course  in  a  few  days  or  even 
hours,  ending  in  the  formation  of  serous  fluid,  which  is  reabsorbed ;  in 
others  ulceration  takes  place,  and  the  nail  is  undermined  and  eventually 
cast  off.  Deep  whitlow  is  a  much  more  serious  affair.  The  palmar 
aspect  of  the  last  phalanx  of  one  of  the  fingers  is  the  common  situ- 
ation. The  finger  becomes  painful  in  a  day  or  two  after  an  injury ; 
then  it  begins  to  throb,  particularly  when  allowed  to  hang  down ;  the 
patient  passes  sleepless  nights  ;  the  pulse  increases  in  frequency  and 
the  temperature  rises.  Suppuration  is  taking  place,  and  nothing  but 
the  evacuation  of  pus  and  the  relief  of  tension  will  get  rid  of  the 
suffering. 

Treatment. — At  the  \'er}^  commencement  of  the  disease  the  hand 
may  be  placed  for  an  hour  or  longer  in  a  hot  solution  of  corrosive  sub- 


INJURIES  AND  DISEASES  OF  MUSCLES,   TENDONS,  AND  BURS.E.     IO9 

limate  in  the  hope  of  destroying  the  germs  and  averting  suppuration. 
If  at  the  end  of  two  or  three  days  the  symptoms  show  no  sign  of 
abatement,  the  only  treatment  of  value  is  free  incision.  When  the 
terminal  phalanx  is  affected  the  tissues  should  be  divided  down  to  the 
bone.  In  the  case  of  the  first  or  second  phalanx  the  pus  is  probably 
no  deeper  than  the  tendon,  so  that  opening  the  sheath  is  sufficient,  and 
relief  will  speedily  follow.  The  rest  of  the  treatment  consists  in  strict 
antiseptic  dressings. 

Ganglion — or  "  weeping  sinew,"  as  some  of  the  old  surgeons 
called  it — is  a  collection  of  fluid  in  connection  with  a  tendon-sheath. 
Its  favorite  situation  is  the  back  of  the  hand  or  wrist,  w^here  it  appears 
as  a  round,  firm  tumor  of  varying  density,  causing  little  or  no  incon- 
venience, except  in  such  occupations  as  require  constant  use  of  the 
affected  tendon.  This  little  tumor  is  a  cyst  containing  the  synovial 
fluid,  but  generally  changed  to  a  jelly-like  consistence.  Sometimes 
the  tendon-sheath  is  distended  for  some  distance,  and  the  fluid  contains 
melon-seed  bodies  and  is  thick  and  gelatinous.  This  form,  sometimes 
called  compound  ganglion,  is  found  in  the  palm,  while  the  simple  cyst 
is  common  on  the  back  of  the  hand  and  wrist.  The  causes  are  strains, 
overuse,  or  slight  injuries  frequently  repeated. 

Treatment. — Three  methods  of  treatment  are  in  vogue : 

1.  Subcutaneous  rupture.  This  may  be  effected  by  a  quick  and 
forcible  pressure  of  the  thumb  or  a  smart  blow.  The  contents  of  the 
cyst  are  forced  along  the  sheath  or  into  the  surrounding  tissues,  and 
are  then  absorbed.  The  objections  to  this  method  are  that  the  cyst 
rapidly  refills,  and  it  may  then  be  so  thick  and  strong  that  it  cannot 
thus  be  ruptured. 

2.  Subcutaneous  division  by  a  small  knife  or  flat  needle. 

3.  Cutting  down  upon  the  cyst  and  excising  it  is  the  most  effectual 
of  all  methods,  and  when  carried  out  aseptically  is  perfectly  safe. 

Compound  ganglion  is  a  serious  affection,  and  the  results  of  the 
most  careful  treatment  are  often  unsatisfactory.  Syme's  method  of 
freely  laying  open  the  sheath  was  successful  in  his  hands  even  before 
he  resorted  to  antiseptic  surgery.  The  sheath  should  be  opened  above 
and  below  the  annular  ligament,  the  melon-seed  bodies  removed,  and 
thorough  drainage  effected.  Suppuration  is  disastrous,  for  it  is  almost 
sure  to  extend  to  the  joint,  and  the  tendons  themselves  are  liable  to 
slough.  This  operation  should  never  be  undertaken  except  under  the 
most  rigid  asepsis,  and  in  any  case  a  guarded  prognosis  should  be 
made. 

Dupuytren's  contraction  is  an  affection  of  the  hand  found  in 
men  (rarely  in  women)  of  middle  or  advanced  life.  Its  characteristics 
are  flexion  of  the  fingers  at  the  metacarpo-phalangeal  joint ;  the  palmar 
fascia  is  tense  and  firmly  adherent  to  the  skin,  while  great  resistance  is 
felt  when  an  attempt  is  made  to  straighten  the  fingers.  In  aggravated 
cases  the  fingers  are  tied  rigidly  down  into  the  palm  of  the  hand.  It  is 
generally  associated  with  gout,  but  engineers,  fitters,  and  other  mechanics 
are  liable  to  suffer  from  it. 

Ti'eatvient. — In  the  early  stages  massage  and  passive  movements  of 
the  affected  fingers  may  arrest  the  progress  of  the  deformity.  A  splint 
may  be  worn  at  night,  and  a  variety  of  complicated  appliances  have 


no 


SURGICAL    DIAGNOSIS  AND    TREATMENT. 


been  invented  by  instrument-makers.  These  have  not  been  very  satis- 
factory. When  the  finger  is  so  far  contracted  as  to  form  a  right  angle, 
operative  treatment  is  necessary.  Various  procedures  have  been  resorted 
to.  Adam's  method  consists  in  subcutaneous  section  at  many  points 
with  a  fine  tenotomy  knife.  The  hand  having  been  carefully  tlisinfected 
and  held  in  an  deviated  position  for  a  few  minutes  to  limit  the  amount 
of  hemorrhage,  incisions  are  made  in  the  palm  at  those  points  where 
the  skin  is  still  movable  over  the  fascia.  This  is  continued  down  the 
fingers,  each  resisting  point  being  severed  until  the  digits  can  be  thor- 
oughly extended.  The  small  openings  can  be  sealed  by  iodoform  and 
collodion,  and  the  hand  placed  immovably  upon  a  palmar  splint  for 
three  or  four  days.  Passive  motion  should  then  be  continuously  carried 
out.     In  favorable  cases  two  weeks  suffice  to  effect  a  cure. 

Diseases  of  Bursse. — Between  tendon  and  bone,  over  bony 
prominences,  and  in  fact  at  any  point  where  there  is  much  friction, 
bursse  exist,  either  congenital  or  acquired.  They  may  communicate 
with  the  cavity  of  a  joint,  in  which  case  they  must  be  regarded  as 
offsets  of  the  synovial  sac.  In  most  cases  they  are  simply  cavities  in 
the  cellular  tissue. 

Wounds  of  bursae,  if  not  infected,  heal  rapidly.  Punctured  and 
lacerated  wounds  and  contusions  are  liable  to  prove  troublesome,  owing 
to  the  friction  of  the  adjacent  structures.  The  treatment  of  such  injuries 
is  by  rest,  thorough  cleansing,  drainage,  and  pressure. 

Bursitis,  or  inflammation  of  bursse,  is  commonly  met  with  in 
the  form  of  "  housemaid's  knee,"  the  bursa  in  front  of  the  patella  being 

the  seat  of  inflammation  (Fig.  45).  The 
"  student's  elbow  "  is  an  inflammation  of  the 
bursa  over  the  olecranon,  due  to  pressure  of 
the  elbow  upon  a  hard  table  while  absorbed 
in  study.  The  bursa  lying  between  the  tendo 
Achillis  and  the  os  calcis  is  another  that  is 
liable  to  inflammation.  It  is  recognized  by  a 
swelling  which  occupies  the  space  on  each 
side  of  the  tendon,  and  is  distinguished  from 
an  effusion  into  the  ankle,  which  would  ap- 
pear in  front  of  the  joint. 

Bursitis   may  be   acute,  chronic,   or  sup- 
purativ^e. 

Acute  bursitis  is  nearly  always  the  result 
of  injury.  The  housemaid  upon  her  knees 
scrubbing  floors  bruises  the  prepatellar  bursa 
and  inflammation  follows.  Syphilis,  gout,  and 
tuberculosis  are  also  regarded  as  causes.  The 
early  symptoms  of  bursitis  are  swelling,  red- 
ness, pain,  and  pyrexia.  The  bursa  being,  in  its  natural  state,  an 
unfilled  cavity,  a  certain  amount  of  fluid  can  collect  without  pro- 
ducing tension ;  hence  pain  is  not  an  early  symptom.  In  super- 
ficial bursae  diagnosis  is  easy,  but  in  the  case  of  deep  bursae  it  may 
be  difficult.  Here  we  have  little  or  no  swelling  to  guide  us,  and  our 
reliance  must  be  placed  upon  our  knowledge  of  the  action  of  the  mus- 
cles.    Inflammation  of  the  bursa  under  the  deltoid  is  recognized  from 


Fig.  45. — Prepatellar  bursa, 
contents  aspirated ;  no  return 
(from  a  photograph  in  the  col- 
lection of  Dr.  Lincoln,  Wa- 
basha, Minn.). 


INJURIES  AND   DISEASES   OF  JOINTS.  I  1 1 

the  fact  that  rotation  of  the  arm  is  free  from  pain  when  the  Hmb  is  in 
the  position  of  moderate  abduction,  but  excessively  painful  when  by 
forced  adduction  or  abduction  the  sac  is  made  tense.  In  the  case  of 
the  bursa  under  the  psoas  we  have  freedom  from  pain  when  the  thigh 
is  rotated  in  the  position  of  flexion,  but  intense  pain  when  this  move- 
ment is  carried  out  with  the  limb  in  extension. 

Suppuration  is  recognized  by  the  occurrence  of  a  chill  or  a  marked 
rise  in  temperature  with  increased  severity  of  all  the  symptoms. 
Chronic  bursitis  is  a  sequel  of  the  acute  form  or  may  result  from 
tuberculosis  or  syphilis. 

Trcatinejit. — In  the  acute  form  rest,  cold  applications,  and  pressure 
may  be  tried.  If  these  measures  do  not  give  relief,  the  sac  should  be 
aspirated  and  firm  pressure  maintained  by  means  of  a  bandage.  When 
suppuration  takes  place  the  cavity  should  be  laid  open,  irrigated  with 
corrosive  sublimate  i  :  2000,  drained,  and  dressed  antiseptically. 


CHAPTER  V. 
INJURIES   AND    DISEASES   OF   JOINTS. 

I.  INJURIES  OF  JOINTS. 

In  examining  any  joint  we  must  keep  before  our  minds  the  follow- 
ing structures,  any  or  all  of  which  may  be  implicated  when  an  articula- 
tion is  injured  or  diseased  :  viz.  the  bones,  articular  cartilages,  synovial 
membrane,  ligaments,  and  muscles.  The  common  injuries  of  joints  are 
contusions,  sprains,  wounds,  and  dislocations. 

Contusions. — Direct  violence,  such  as  blows,  kicks,  or  falls  upon 
a  joint,  is  important,  from  the  fact  that  more  or  less  hemorrhage  may 
take  place  into  the  articular  cavity,  causing  distention  and  affording  a 
good  culture-soil  for  septic  germs  should  they  chance  to  gain  an 
entrance.  When  the  bruise  is  not  severe  and  no  hemorrhage  results, 
rest  and  the  application  of  warm  fomentations  will  soon  restore  normal 
conditions. 

Sprains  are  more  serious.  A  forcible  twist  of  a  joint,  as  when  a 
person  "  turns  his  ankle,"  is  liable  to  cause  more  or  less  laceration  of 
the  tissues.  The  ligaments  may  be  stretched  or  torn  across,  and  may 
detach  a  thin  scale  from  the  bone,  the  synovial  membrane  may  be  rent, 
the  muscles  may  be  lacerated  or  overstretched,  and  their  tendons  thrown 
out  of  their  grooves.  In  severe  sprains  the  bones  themselves  are  wrenched 
asunder,  but  slip  back  into  place.  Between  a  sprain  of  this  kind  and  a 
dislocation  the  only  difference  is  that  in  the  one  case  the  bones  return 
to  their  normal  position,  while  in  the  other  they  remain  dislocated.  It 
is  a  common  saying  that  a  bad  sprain  is  worse  than  a  fracture,  and  to 
a  certain  extent  this  is  true.  If  much  laceration  of  tissues  occur  and 
the  most  careful  treatment  be  not  employed,  permanent  weakness  of 
the  joint  may  result. 

The  symptoms  of  sprain  are — 


112  SL'KGICAL    n/AGiXOSIS  AND    TREATMENT. 

(i)  Severe  pain  following  a  forcible  twist  or  wrench  of  a  joint. 
Sprains  occur,  as  a  rule,  when  the  muscles  are,  so  to  speak,  taken  off 
their  guard,  and  the  same  is  true  of  dislocations.  If  the  muscles  were 
prepared  for  the  strain  and  thrown  into  strong  resisting  contraction,  it 
is  doubtful  whether  sprains  or  dislocations  would  ever  occur.  The 
pain  is  of  a  severe  and  sickening  character.  The  patient  becomes 
deathly  pale,  nauseated,  and  perhaps  falls  fainting  to  the  ground.  As 
the  more  intense  pain  passes  off  a  feeling  of  numbness  succeeds,  with 
a  dull  aching  due  to  pressure  on  the  nerves.  Movement  of  the  limb 
causes  unbearable  pain.  There  can  usually  be  felt  one  or  more  spots 
which  are  intensely  tender  to  pressure.  These  correspond  to  the 
lacerated  ligaments. 

(2)  Swelling  sets  in  almost  immediately,  particularly  if  there  be 
rupture  of  vessels  in  or  about  the  joint.  When  the  swelling  is  due  to 
inflammatory  exudation,  it  is  longer  delayed,  and  may  not  be  observed 
until  the  end  of  twenty-four  or  forty-eight  hours. 

(3)  Discoloration  of  the  skin  follows  the  injury,  varying  in  hue  from 
a  greenish-yellow  to  black,  and  if  there  be  much  extravasation  of  blood, 
the  tissues  about  the  joint  may  be  filled  with  it. 

Errors  in  Diagnosis. — Sprains  may  be  mistaken  for  dislocation,  for 
fractures  near  joints,  or  in  the  case  of  the  ankle  for  talipes  valgus. 

Differential  Diagnosis  betzveen  Sprain  and  Dislocation. 

Sprain.  Dislocation.  . 

Deformity. 

Only  the  result  of  swelling.  Great  deformity,  and   bones  felt  in  abnormal 

position. 
Pain. 

Pain  of  a  peculiar  sickening  character,  after-      Severe  pain,  even  when  at  rest,  not  relieved 
ward  numbness,  relieved  by  pressure  and  until  reduced, 

rest. 

Mobility. 

Normal    mobility,   except    as    impaired    by      Want  of  normal  mobility,  both  in  direction 
swelling  and  pain.  and  degree. 

Fracture  of  the  lower  end  of  the  fibula  is  often  difficult  to  dis- 
tinguish from  a  severe  sprain  of  the  ankle.  The  diagnosis  can  be 
settled  by  finding  the  characteristic  deformity  of  this  fracture  and  a 
particularly  tender  spot  over  the  fibula  by  digital  pressure. 

Spurious  talipes  valgus  (flat-foot)  need  not  cause  any  difficulty,  as  in 
this  case  there  is  a  history  of  a  gradual  and  prolonged  debility,  and  not 
a  sudden  wrench  as  in  sprain. 

Treatment. — In  mild  cases  cold  applied  immediately  after  the  injury 
will  tend  to  prevent  swelling  and  effusion  into  the  joint  by  constricting 
the  blood-vessels.  If  seen  several  hours  after  the  accident,  hot  fomen- 
tations generally  afford  most  relief  Perfect  rest  in  the  elevated  position 
is  of  the  greatest  importance,  and  will  relieve  pain  better  than  liniments 
or  lotions.  Of  all  appliances,  a  flannel  or  an  elastic  bandage  applied 
over  a  thin  sheeting  of  absorbent  cotton  gives  the  greatest  support  and 
relief  to  the  joint.  In  the  case  of  the  ankle  care  should  be  taken  to 
fill  in  the  hollows  around  the  malleoli  with  cotton  before  applying  the 


INJURIES  AND   DISEASES   OF  JOINTS.  I  1 3 

bandage.  When  there  is  much  laceration  of  Hgaments  the  joint  should 
not  be  used  until  perfect  repair  shall  have  taken  place,  otherwise  there 
is  a  risk  of  permanent  weakness.  In  cases  of  ordinary  seventy  it  is 
sufficient  for  the  patient  to  lay  up  for  a  few  days,  and  then,  with  the 
joint  firmly  bandaged,  he  can  move  about  on  crutches  in  the  case  of  a 
sprained  ankle  or  knee,  or  with  the  arm  in  a  sling  when  the  wrist  or 
elbow  is  the  injured  joint. 

Massage  is  of  great  value  in  protracted  cases,  or  even  in  the  early 
stages  when  the  acute  inflammation  has  subsided.  It  can  be  employed 
as  follows :  Raise  the  limb  and  relax  the  muscles.  Begin  with  very 
hght  movements,  commencing  above  the  joint,  where  there  is  still  no 
swelling,  and  working  downward  to  the  articulation.  The  direction  of 
the  movements  must  always  be  toward  the  trunk,  using  the  thumbs, 
the  pulp  of  the  fingers,  or  the  palm  of  the  hand  according  to  the  part 
of  the  limb  that  is  being  manipulated.  The  tender  spots  are  the  last 
to  be  touched.  Swelling  by  this  means  gradually  subsides,  and  as  the 
circulation  improves  absorption  rapidly  takes  place.  Attention  is  next 
paid  to  the  parts  where  extravasation  is  greatest,  and  by  the  thumbs  or 
fingers  these  spaces  are  rubbed,  moving  in  small  circles  upon  the  skin, 
and  gradually  increasing  the  pressure  as  the  structures  can  tolerate  the 
operation.  Passive  motion  of  the  joint  can  be  combined  with  these 
movements,  for  even  in  the  case  of  ruptured  ligaments  a  considerable 
degree  of  motion  can  be  effected  without  throwing  the  ligaments  into 
a  state  of  tension. 

Wounds  of  Joints. — Wounds  of  joints  must  always  be  looked 
upon  as  serious  injuries.  They  are  common  among  artisans,  such  as 
ship-carpenters,  who  work  with  edged  tools.'  As  gunshot  injuries  they 
are  common,  and  they  also  occur  as  complications  of  dislocations  and 
fractures.  Even  in  non-penetrating  wounds  of  joints  the  injury  is  a 
serious  one,  for  if  the  wound  be  allowed  to  suppurate  the  cavity  of  the 
joint  may  be  opened  into  and  become  the  seat  of  serious  mischief. 
Large  wounds,  laying  open  to  view  the  articulating  surfaces  of  the 
joint,  are  self-evident  and  easily  diagnosed.  In  perforating  wounds, 
however,  it  is  not  always  easy  to  prove  that  the  joint  has  been  cut 
into.  The  most  important  sign  is  the  escape  of  the  synovial  fluid  more 
or  less  mixed  with  blood.  It  can  be  readily  recognized  by  its  viscidity 
when  a  drop  of  it  is  examined  between  the  thumb  and  finger.  If  the 
amount  of  this  fluid  is  large,  it  may  be  regarded  as  pathognomonic  of  a 
wound  of  a  joint.  It  may  happen  that  a  small  bursa  is  opened  into 
which  does  not  communicate  with  the  articulation,  but  in  this  case  the 
amount  of  fluid  is  small,  and  it  ceases  to  come  away  after  the  first  gush, 
while  in  the  case  of  the  true  synovia  it  can  be  made  to  ooze  out  on 
flexion  and  extension  of  the  joint.  When  no  synovial  fluid  escapes, 
the  rapid  filling  of  the  joint  with  blood  would  be  strong  evidence  of  a 
penetrating  wound. 

Treatmoit. — Provided  the  wound  is  made  by  an  aseptic  instrument 
and  no  infection  is  allowed  to  gain  access  to  the  joint,  these  wounds 
are  free  from  danger.  An  incision  in  the  synovial  membrane  or  in  any 
other  of  the  joint-structures,  if  kept  thoroughly  aseptic,  will  heal  as 
readily  as  in  any  other  tissues.  The  danger  lies  in  the  ease  With  which 
septic  germs  gain   an  entrance,  and  in  the  difficulty  of  keeping  the 

8 


114  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

wound  tliorouy;hl\'  drained.  Asepsis  here  is  evcrythin<^  in  treat- 
ment. 

Before  touching  the  wound  itself  the  skin  for  a  considerable  dis- 
tance around  should  be  thoroughly  washed  with  soap  and  water,  and 
afterward  with  cither  alcohol  or  turpentine,  and  lastly  with  corrosive- 
sublimate  solution.  The  limb  should  be  wrapped  with  sterilized  towels. 
After  cleansing  the  wound  from  all  clots  and  impurities,  the  finger, 
scrupulously  clean,  assisted,  if  need  be,  by  a  probe,  should  explore 
the  wound.  It  is  often  necessary  to  enlarge  the  wound  in  order  that 
pieces  of  clothing  carried  in  by  the  bullet  or  penetrating  object  and  all 
particles  of  bone  can  be  effectually  removed.  After  thoroughly  irri- 
gating the  joint  with  sterilized  water  a  drainage-tube  is  inserted,  pass- 
ing through  the  joint  from  side  to  side  if  necessary.  A  full  antiseptic 
dressing  and  immobilization  of  the  limb  on  a  splint  complete  the  ope- 
ration. Should  the  joint  become  septic,  the  wound  and  every  sinus 
about  it  must  be  opened  up,  washed  out,  and  drained,  and  the  process 
repeated  as  often  as  necessary.  In  gunshot  wounds,  which  form  a  very 
dangerous  class  of  these  cases,  the  bones  are  often  so  destroyed  as  to 
require  the  removal  of  a  considerable  part  of  their  articular  ends.  It 
is  better  to  make  an  atypical  resection  rather  than  the  typical  operation, 
in  order  to  leave  the  joint  as  little  impaired  as  possible.  Such  cases 
are  apt  to  result  in  bony  ankylosis. 

Treves  strongly  advocates  constant  irrigation  of  the  joint  night  and 
day  to  avoid  the  retention  within  the  cavity  of  septic  and  decomposing 
materials,  and  excellent  results  have  been  obtained  in  very  unpromising 
cases. 

When  thorough  drainage  can  be  maintained  there  is  little  likelihood 
of  great  tension  in  the  joint.  Should  this  occur,  the  fluid  must  be  got 
rid  of  by  free  openings  and  extra  drainage-tubes.  When  there  is 
danger  of  ankylosis  resulting  the  limb  should  be  kept  in  the  position 
w'hich  will  be  most  useful  to  the  patient  in  the  event  of  a  stiff  joint. 

Dislocations. — When  one  of  the  bones  entering  into  the  forma- 
tion of  a  joint  is  permanently  displaced  from  its  normal  relations  with 
the  other  bones,  it  is  said  to  be  dislocated.  In  sprains  a  temporary 
displacement  may  take  place,  the  bones  immediately  returning  to  their 
normal  relations. 

Dislocations  are  classified  as  traumatic  when  the  result  of  violence ; 
patlwlogical  when  the  bones  have  become  displaced  owing  to  destruc- 
tive changes  in  the  joint,  as,  for  instance,  in  disease  of  the  hip  or  knee  ; 
congenital  when  occurring  in  titcro  and  as  a  result  of  non-development ; 
complete  when  the  articular  surfaces  are  entirely  separated  or  only  touch 
each  other  at  their  edges  ;  incomplete,  or  subluxations  or  partial,  when 
the  surfaces  are  not  completely  separated.  For  every  ten  cases  of 
fractures  you  meet  with,  you  may  expect  one  of  dislocation.  Dis- 
locations occur  at  any  time  of  life,  but  the  most  common  period  is 
between  twenty  and  thirty  years  of  age. 

The  causes  of  dislocation  are  predisposing  and  immediate.  Some 
people  are  naturally  loose-jointed ;  their  ligaments  are  lax ;  the  area 
of  contact  between  the  articular  surfaces  is  small ;  and,  altogether,  the 
joints  have  not  the  normal  power  of  resistance.  A  joint  distended 
with  fluid  is  thereby  predisposed  to  dislocation.     The  immediate  causes 


INJURIES  AND  DISEASES  OF  JOINTS.  II5 

may  be  summed  up  in  a  few  words — external  violence  and  muscular 
action. 

In  examining  a  patient  for  dislocation,  always  strip  the  suspected 
joint  of  all  clothing,  and  also  its  fellow  on  the  opposite  side  of  the 
body,  which  will  serve  for  purposes  of  comparison.  Four  features 
must  be  kept  in  mind,  and,  as  a  rule,  these  four  will  settle  the  ques- 
tion. They  are — Loss  of  symmetry  ;  want  of  normal  mobility  ;  change 
in  direction  of  the  axis  of  the  dislocated  bone ;  constant  pain,  relieved 
only  by  reduction. 

In  certain  forms  of  dislocation  the  end  of  the  displaced  bone  can  be 
felt  in  its  abnormal  position.  A  systematic  manner  of  making  the 
examination  would  be  the  following : 

{a)  History. — Falls  are  common  causes  of  the  accident.  A  fall  upon 
the  shoulder  is  likely  to  dislocate  the  upper  end  of  the  humerus  or 
fracture  the  clavicle.  A  fall  upon  the  outstretched  hand  will  dislocate 
the  elbow  of  a  child,  but  fracture  the  humerus  of  an  adult. 

(/;)  Inspectio7t. — A  glance  may  decide  the  change  in  outline  and 
show  an  unmistakable  displacement  of  the  bones.  The  eye  may  be 
assisted  by  measurements,  as  in  dislocation  of  the  hip,  where  shorten- 
ing or  lengthening  of  the  limb  affords  important  evidence.  The  head 
of  the  humerus  in  the  axilla  may  press  upon  the  veins  and  cause  edema 
of  the  arm. 

(r)  Palpation. — The  finger  can  be  placed  over  the  bony  prominences 
and  their  position  determined,  as  in  the  case  of  the  condyles  of  the 
humerus  and  the  olecranon  at  the  elbow.  Motion,  both  active  and 
passive,  must  be  tested.  Voluntary  movements  are  always  restricted, 
and  may  be  entirely  lost.  Passive  motion  cannot,  as  a  rule,  be  tested 
until  the  patient  has  been  placed  under  an  anesthetic.  When  super- 
ficial palpation  affords  no  satisfactory  evidence  deep  pressure  will 
frequently  do  so. 

Should  these  methods  fail  to  satisfy  the  surgeon,  he  can  gain  much 
additional  evidence  by  placing  the  patient  under  an  anesthetic.  Motion, 
which  was  before  restricted  on  account  of  pain,  can  now  be  freely 
tested,  and  any  want  of  normal  mobility  accurately  determined. 
Great  care  must  be  taken  to  exclude  fractures  in  the  neighborhood 
of  the  joint,  severe  sprains,  and  separation  of  the  epiphyses.  Crepitus 
is  pathognomonic  of  fracture,  but  in  some  cases  it  is  wanting.  It  may 
be  present  in  dislocations,  owing  to  the  fact  that  a  dislocation  and  frac- 
ture may  exist  together.  A  dull  rubbing  sound,  due  to  the  movement 
of  a  dislocated  bone  on  tendons  or  fascia,  must  not  be  mistaken  for 
crepitus. 

In  obscure  cases,  and  especially  when  dislocation  and  fracture  are 
combined,  the  .i'-rays  may  settle  the  diagnosis  in  a  most  satisfactory 
manner  (see  chapter  on  "  The  Rontgen  Rays  in  Diagnosis  "). 

When  we  consider  the  structure  of  a  joint,  it  is  not  difficult  to 
understand  what  takes  place  when  dislocation  occurs.  One  or  more 
of  the  ligaments  must  be  torn  :  rarely  does  stretching  alone  occur. 
The  pain  of  dislocation  is  produced  by  two  factors — viz.  the  violence 
to  the  ligaments  and  the  pressure  of  the  head  of  the  bone  in  its  new 
position.  The  capsule  of  the  joint  also  suffers,  and  it  is  quite  common 
to  have  this  membrane  torn.     In  joints  of  the  ball-and-socket  variety 


Il6  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

the  bone  is  pushed  through  a  rent  in  the  capsule,  and  in  some  cases 
affords  no  little  trouble  to  get  it  back  through  the  opening  which  it  has 
made.  The  muscles  also  suffer,  for  they  not  infrequently  are  over- 
stretched, lacerated,  or  torn  from  their  attachments,  perhaps  bringing 
away  a  scale  of  bone  with  them.  The  bones  thcmscKcs  do  not  always 
escape.  At  the  shoulder-joint  the  dislocated  head  of  the  humerus 
often  breaks  off  a  piece  of  the  rim  of  the  glenoid  cavity ;  the  head  of 
the  femur  may  detach  a  part  of  the  lip  of  the  acetabulum  ;  the  coronoid 
process  of  the  ulna  may  be  carried  away  in  backward  dislocation  of  the 
elbow. 

Complications  may  give  no  end  of  trouble.  Fracture  and  disloca- 
tion combined  are  found  at  the  shoulder,  the  elbow,  the  hip,  aiid  in  fact 
may  occur  at  any  joint.  The  displaced  bone  may  compress  arteries, 
veins,  nerves,  and  neighboring  organs ;  the  bruising  and  tearing  of 
soft  parts  may  add  to  the  seriousness  of  the  injury,  and  the  bone  may 
be  driv'en  through  the  skin,  thus  forming  a  compound  dislocation.  In 
view  of  these  conditions  it  is  most  important  that  a  dislocation  be 
reduced  at  the  earliest  possible  moment.  Pain,  which  continues  as 
long  as  the  part  remains  overstretched,  will  cease  almost  as  soon  as 
the  bone  is  replaced ;  the  displacement,  when  once  rectified,  has  no 
tendency  to  return  ;  the  rent  in  the  capsule  speedily  heals  and  the  nor- 
mal condition  of  things  is  restored.  The  only  conditions  which  war- 
rant delay  in  reducing  a  dislocation  are  great  swelling  and  inflammation 
in  and  about  the  joint,  also  profound  shock  from  associated  injuries. 
While  I  mention  the  existence  of  swelling  and  inflammation  as  a  reason 
for  delay,  I  would  also  urge  that  when  it  is  possible  reduction  is  the 
very  best  means  of  getting  rid  of  these  conditions.  Shock  is  important 
as  prohibiting  the  use  of  anesthetics  or  painful  manipulation. 

Trcatmoit. — Two  difficulties  confront  us  in  reducing  a  dislocation  : 
The  bone  may  not  readily  come  back  through  the  rent  which  it  has 
made  in  the  capsule  or  it  may  become  locked  against  another  bone  or 
be  caught  in  a  ligament,  tendon,  or  dense  fascia.  The  other  obstacle 
is  the  contraction  of  the  muscles  which  pass  over  the  joint.  Immedi- 
ately after  a  dislocation  the  muscles  become  relaxed,  but  after  a  time 
they  regain  their  contractility  and  become  rigidly  contracted.  This 
action  tends  to  push  the  ends  of  the  bones  farther  and  farther  past  each 
other,  and  greatly  increases  the  difficulty  of  bringing  them  back  to 
position.  To  overcome  this,  steady  traction  must  be  made  upon  the 
muscles  until  by  sheer  fatigue  they  become  relaxed.  Under  an  anes- 
thetic relaxation  is  immediate  and  complete. 

Two  methods  of  reduction  are  in  vogue : 

I.  Extension  and  Counter-extension. — By  this  method  steady  traction 
is  made  until  the  muscles  relax  or  perhaps  iDCCome  torn,  and  the  bone  by 
sheer  force  is  freed  from  its  unnatural  position,  when  with  a  snap  the 
muscles  draw  it  into  its  proper  place.  A  good  example  of  this  method 
is  seen  in  the  case  of  the  shoulder-joint,  where,  by  placing  the  heel  in 
the  axilla  to  steady  the  trunk,  traction  is  made  upon  the  arm.  and  the 
bone  slips  back  with  a  dull  sound  into  the  glenoid  cavity.  The  older 
surgeons  were  in  the  habit  of  reducing  luxations  of  the  hip  by  means 
of  pulleys  and  cords,  which,  adding  immensely  to  the  power,  caused 
something  to  give  way.     We  seldom  see  mechanical  appliances  of  this 


INJURIES  AND   DISEASES   OF  JOINTS.  11/ 

description  now,  for  in  the  second  method  we  have  something  more 
rational  and  scientific,  and  at  the  same  time  generally  applicable. 

2.  Manipulation. — This  is  adapted  to  the  ball-and-socket  joints,  the 
articulations  which  are  most  complicated  and  likely  to  give  most 
trouble.  The  procedure  aims  to  relax  the  muscles,  and  then  by  suitable 
movements  to  free  the  head  of  the  bone  from  its  entanglements,  bring 
it  back  through  the  rent  in  the  capsule,  and  finally  into  its  normal 
position.  These  manipulations  will  be  described  under  Special  Dis- 
locations. The  after-treatment  of  dislocations  is  the  same  as  that  of 
sprains.  Little  is  needed  in  the  way  of  retentive  apparatus,  for  there  is 
but  slight  tendency  to  recurrence.  At  the  same  time,  the  joint  should 
be  kept  at  rest  to  allow  the  torn  structures  to  heal  and  to  regain  their 
normal  firmness  and  strength.  Inflammation  is  seldom  a  source  of 
trouble,  but  should  it  take  place  cold  applications  or  evaporating 
lotions  are  generally  all  that  are  demanded.  Care  must  be  taken  not 
to  keep  the  joint  too  long  at  rest,  for  adhesions  may  result  which  will 
impair  its  movements.  Passive  motion,  cautiously  carried  out,  may  be 
begun  by  the  end  of  the  first  week,  and  massage,  as  in  the  case  of 
sprains,  will  be  found  a  valuable  adjunct. 

Old  dislocations  are  difficult  to  deal  with.  Changes  in  the  structures 
take  place  which,  after  a  time,  render  reduction  a  physical  impossibility. 
The  muscles  become  fibrous,  and  are  liable  to  rupture  before  they  can 
be  stretched  to  their  former  length.  The  head  of  the  bone  in  its  new 
position  becomes  surrounded  with  fibrous  tissue,  forming  a  new  socket. 
Over  the  normal  socket,  as  at  the  acetabulum  or  glenoid  fossa,  the 
capsule  is  stretched  and  may  become  firmly  attached,  so  that  the  bone 
cannot  be  brought  back  to  position.  Still,  it  sometimes  happens  that 
good  results  are  attained  even  after  long  periods  of  luxation.  In  a  boy 
ten  years  of  age  the  writer  reduced  a  dislocation  of  the  femur  into  the 
obturator  foramen  after  an  interval  of  fifty-six  days,  in  another  after 
twelve  weeks,  both  by  manipulation  ;  and  in  a  dislocation  of  the  lower 
jaw  after  a  period  of  six  months. 

In  the  treatment  of  old  luxations  the  same  methods  as  are  suitable 
for  recent  dislocations  may  be  tried.  Much  greater  force  will,  however, 
be  necessary  to  break  up  the  adhesions  that  have  formed  and  to  stretch 
the  muscles  to  their  former  length.  It  is  difficult  to  judge  of  the  amount 
of  force  that  it  is  safe  to  employ  in  cases  of  this  kind.  A  moderate 
amount  of  traction  will  be  of  no  avail,  and  too  much  may  lead  to 
serious  consequences.  The  neck  of  the  humerus  or  of  the  femur  may 
be  broken,  vessels  may  be  torn  across,  and  even  when  every  obstacle 
has  given  way  and  the  bone  is  brought  to  its  original  position,  the  last 
state  may  be  worse  than  the  first.  As  a  guide  in  the  management  of 
such  cases  the  following  directions  may  be  useful :  Always  put  the 
patient  under  an  anesthetic.  Break  up  the  adhesions  by  manipulation 
and  rotation,  and  avoid  any  leverage  which  is  apt  to  fracture  the  bone. 
Wrap  the  limb  in  a  wet  towel  to  prevent  injury  to  the  skin.  If  manip- 
ulation fail,  try  the  pulleys.  Traction  must  be  slow  and  steady,  and 
sudden  jerks  avoided.  While  this  is  being  done  the  surgeon,  by 
direct  manipulation,  follows  the  head  of  the  bone,  and  as  soon  as  it  is 
brought  down  endeavors  to  force  it  into  its  socket. 

Compound  dislocations  must  be  treated  on  much  the  same  prin- 


ii8 


SURGICAL    DIAGNOSIS  AND    TKEATMENr. 


ciples  as  compound  fractures.  We  have  here  the  serious  comphcation 
of  a  wound  into  the  joint,  and  the  dani^er  of  infection  by  septic  germs, 
and  consequently  suppurative  arthritis.  It  will  often  be  a  nice  point  to 
decide  whether  the  proper  course  is  to  amputate  or  to  attempt  to  save 
the  limb.  The  amount  of  laceration  and  destruction  of  tissue,  the 
interference  with  vascular  supply,  and  the  probability  of  securing  a 
useful  limb  will  have  to  enter  into  the  calculation.  At  the  knee  the 
displaced  bone  may  press  upon  the  popliteal  vessels  so  as  to  rupture 
their  inner  coats,  while  the  outer  are  left  intact.  While  the  absence 
of  hemorrhage  would  lead  us  to  suppose  that  the  vessels  were  uninjured, 
their  giving  way  at  a  later  period  will  lead  to  the  most  serious  results. 

When  the  conditions  seem  favorable  for  saving  the  joint  the  greatest 
care  must  be  taken  in  the  dressing  of  the  wound.  Fragments  of  bone 
must  be  removed,  the  joint  freed  from  all  contamination,  such  as  dirt 
or  clothing,  and  thoroughly  irrigated.  Reduction  is  generally  easy. 
The  wound  should  be  dressed  in  the  usual  manner  and  the  limb  im- 
mobilized by  a  splint.  Thorough  drainage  is  of  the  utmost  conse- 
quence. When  operative  interference  is  demanded  the  choice  will 
rest  between  excision  of  the  joint  and  amputation  of  the  limb. 


Diagnosis  of  5pecial  Dislocations. 

The  I/Ower  Jaw  (Fig.  46). — There  is  only  one  direction  in  which 
the  lower  jaw  can  be  dislocated,  and  that  is  forward.     One  side  may 

be  displaced  (unilateral  dislocation),  or 
both  sides  (bilateral).  The  injury  is  easily 
recognized.  The  causes  are  muscular 
action  and  indirect  violence.  The  acci- 
dent always  happens  when  the  mouth  is 
open.  The  patient  presents  a  peculiar 
appearance  when  the  dislocation  is  bi- 
lateral. The  mouth  is  widely  open  and 
speech  is  difficult.  The  labials  he  cannot 
pronounce  at  all.  He  holds  his  hand 
against  the  jaw  to  prevent  further  dis- 
placement, and  saliva  dribbles  from  his 
mouth.  Place  your  fingers  at  the  angle 
of  the  jaw,  and  you  will  find  in  front  of 
the  ear  a  depression  instead  of  the  natural 
prominence  caused  by  the  condyle.  In 
front  of  this  there  is  a  prominence  due  to 
the  new  position  of  the  bone  and  to  the 
contraction  of  some  of  the  fibers  of  the 
masseter  muscle.  The  jaw  can  be  moved 
downward  to  a  slight  degree,  but  this  is  all.  Pain  is  severe,  owing  to 
stretching  of  the  parts,  except  it  be  a  case  in  which  the  jaw  has  been 
repeatedly  dislocated.  When  only  one  side  of  the  jaw  is  the  seat  of 
luxation,  the  symptoms,  although  not  so  marked,  are  equally  charac- 
teristic. The  lower  jaw  appears  to  be  pushed  toward  the  opposite  side, 
and  therefore  its  teeth  do  not  fit  normally  against  those  of  the  upper. 
The  face  is  not  much  distorted,  and  pain  is  only  felt  at  one  side. 


Fig.  46. — Dislocation  of  lower  jaw. 


INJURIES  AXD   DISEASES   OF  JOINTS.  II9 

In  young  persons  a  partial  dislocation  is  sometimes  met  with  in 
which  the  condyle  is  displaced  slightly  forward  when  the  mouth  is 
widely  opened  as  in  yawning.  The  patient  learns  to  rectify  the 
position  by  pressing  the  chin  upward. 

Errors  in  Diagnosis. — i.  Congenital  dislocation  of  the  jaw  has  been 
mistaken  for  traumatic  unilateral  dislocation.  In  the  congenital  form 
the  movements  are  but  slightly  impaired  or  are  even  normal,  which  is 
never  the  case  in  the  traumatic  variety.  The  upper  teeth  project 
beyond  the  under  teeth.  There  is  absence  of  salivation,  and  one  side 
of  the  face  is  longer  than  the  other. 

2.  Chronic  rheumatoid  arthritis  is  another  disease  which  may  be 
mistaken  for  dislocation.  The  history  shows  that  the  condition  has 
come  on  slowly.  It  is  a  disease  of  old  age,  there  is  no  salivation,  and 
the  same  condition  exists  in  other  joints. 

Treatment. — The  patient,  seated  in  a  chair,  has  his  head  supported 
by  an  assistant.  Protect  your  thumbs  by  folds  of  a  clean  handkerchief, 
and,  placing  one  over  the  molar  teeth  on  each  side,  press  steadily  down- 
ward, while  the  fingers  at  the  same  time  tilt  the  chin  upward.  The 
thumbs  should  be  placed  as  far  back  as  possible.  When  great 
difficulty  is  experienced,  as  in  old  dislocations,  one  side  can  be  reduced 
first,  and  the  other  afterward,  care  being  taken  lest  the  first  be  again 
displaced  while  the  second  is  being  reduced.  In  very  obstinate  cases, 
although  these  are  uncommon,  great  force  has  to  be  employed.  A 
wedge  of  cork  or  wood  may  be  placed  between  the  molar  teeth  and  the 
chin  drawn  upward  with  strong  force ;  or  a  tourniquet  may  be  placed 
over  the  head  and  under  the  chin,  and  screwed  slowly  and  steadily  up 
until  the  jaw  is  brought  into  place.  A  powerful  pair  of  forceps  may 
be  introduced  between  the  last  molar  teeth  and  their  blades  separated 
forcibly.  In  some  cases,  direct  pressure,  made  backward  upon  the 
coronoid  process,  will  prove  successful.  It  rarely  happens  that  this 
process  becomes  entangled  in  the  fibers  of  the  temporal  muscle.  When 
this  occurs  depress  the  chin  before  attempting  to  elevate  it. 

lExamination  of  Injuries  about  the  Clavicle  and  Shoulder. 
— The  most  convenient  position  for  the  examination  of  injuries  about 
the  shoulder  is- to  have  the  patient  seated  upon  a  stool  or  chair  with  his 
back  toward  you.  Place  your  fore  fingers  in  the  suprasternal  notch 
and  pass  them  outward.  You  can  in  this  way  easily  decide  whether 
the  ends  of  the  clavicle  are  in  position.  The  clavicles  are  subcutaneous, 
and  by  passing  the  fingers  along  their  upper  borders  any  irregularity 
in  their  shape  will  decide  the  existence  of  fracture.  From  the  outer 
end  of  the  clavicle  the  finger  can  be  run  along  each  acromion  process 
and  spine  of  the  scapula  to  the  posterior  border  of  this  bone.  Note 
any  tender  spot  or  any  irregularity  in  the  bone.  Next  take  the 
shoulder,  and,  placing  the  hands  flat,  with  a  thumb  upon  each  acromion 
process,  note  whether  the  head  of  the  humerus  can  be  plainly  felt 
beneath  the  hand.  Press  upon  the  deltoid  muscle  and  feel  for  the 
glenoid  fossa  of  the  scapula.  If  the  glenoid  fossa  can  be  felt,  it  is  proof 
of  dislocation  of  the  humerus,  and  then  the  head  of  the  bone  must  be 
sought  for.  It  will  be  found  in  one  of  three  locations — under  the 
glenoid  fossa,  under  the  clavicle,  or  under  the  spine  of  the  scapula. 
When    you    have    found    the    head  of  the    humerus  rotate  the  bone 


120  SL'KG/C.IL   DLl GNOSIS  AND    TREATMENT. 

gcntl}'  by  grasping  the  elbow,  and  notice  whether  or  not  the  head  moves 
with  the  rest  of  the  bone.     If  there  be  fracture,  crepitus  can  be  felt. 

Next  examine  the  coracoid  process.  There  is  a  groov^e  between  the 
pectoralis  major  and  deltoid  which  allows  you  to  feel  it  without  much 
difhcult}-.  Into  this  groove  press  the  points  of  your  fingers  and  find 
the  process.  Observe  whether  it  is  movable  or  whether  pressure  upon 
it  causes  pain  or  crepitus.  From  this  point  the  fingers  can  be  passed 
around  the  shoulders  to  note  any  difference  in  contour  on  the  two 
sides. 

To  examine  the  axilla  raise  the  arm  gently  from  the  side,  and  with 
the  fingers  in  the  axilla  feel  for  the  head  of  the  humerus  and  note  any 
undue  prominence,  always  comparing  the  uninjured  with  the  injured 
side. 

To  examine  the  scapula,  place  the  forearm  of  the  patient  behind  his 
back,  which  throws  the  lower  angle  of  the  scapula  out  from  the  chest- 
wall.  The  margins  of  the  bone  can  be  followed  with  the  fingers,  the 
inferior  angle  grasped,  and  crepitus  or  mobility  noted.  Up  to  this  point 
your  examination  has  been  made  with  the  patient's  back  toward  you ; 
now  stand  in  front  of  him.  Have  him  hold  both  arms  alike,  and  note 
any  difference  in  their  outlines.  Look  for  any  angularity  in  the  arm  or 
forearm  which  would  indicate  fracture,  or  for  undue  projection  of  the 
point  of  the  elbow  which  would  be  evidence  of  dislocation. 

We  continue  the  examination  by  following  the  shaft  of  the  humerus. 
Place  a  thumb  on  the  inner  side  of  the  surgical  neck  of  each  bone,  and 
with  the  fingers  grasp  the  outer  side  ;  in  this  way  the  hand  can  be  run 
down  along  the  bone  to  the  elbow  in  search  of  any  projecting  frag- 
ments or  other  deformity.  Should  any  such  be  found,  grasp  the  arm 
above  the  suspected  spot  with  one  hand  and  with  the  other  rotate  the 
elbow  for  crepitus. 

To  Bxamine  the  Blbow. — Still  standing  in  front  of  the  patient, 
take  his  elbows  into  the  palms  of  your  hands,  with  your  fore  finger 
resting  on  the  tip  of  the  olecranon,  the  thumb  on  the  outer  epicondyle, 
and  the  middle  finger  on  the  inner  epicondyle  of  the  humerus.  In  the 
normal  condition  of  the  joint  these  three  bony  points  are  in  line.  Any 
deviation  from  this  should  be  noted.  Look  for  a  gap  in  the  olecranon 
which  would  indicate  fracture,  or  for  the  sigmoid  notch  of  the  ulna 
which  would  point  to  dislocation.  Now  move  the  joint  and  observe 
whether  its  action  is  free  and  painless.  Place  the  thumb  of  your  left 
hand  just  below  the  outer  condyle,  and  with  the  right  rotate  the 
patient's  wrist ;  the  head  of  the  radius  will  be  felt  rolling  beneath  the 
thumb.  Should  this  mov^ement  be  painful,  you  may  suspect  fracture ; 
the  existence  of  crepitus  will  leave  no  doubt.  Grasp  each  epicondyle 
in  its  turn,  and  attempt  to  move  it  upon  the  rest  of  the  bone,  and  note 
the  power  of  the  patient  to  pronate  and  supinate  the  forearm.  The 
olecranon  is  subcutaneous,  and  the  fingers  can  be  run  along  it  in  search 
of  fracture.  Usually  a  large  gap  into  which  the  end  of  one  or  more 
fingers  can  be  placed  will  be  found  when  this  process  is  fractured.  To 
complete  the  search  follow  the  tendon  of  the  triceps  down  to  its 
insertion  into  the  ulna. 

Dislocation  of  the  Clavicle. — The  dislocations  of  the  clavicle 
are  seven  in  number — three  at  the  sternal  end,  three  at  the  acromial 


INJURIES  AND  DISEASES   OF  JOINTS.  121 

end,  and  one  of  both  ends  simultaneously.  At  the  sternal  end  the 
accident  is  rare,  owing  to  the  great  mobility  of  the  shoulder,  which 
prevents  any  severe  strain  upon  the  sterno-clavicular  joint,  except 
when  the  force  is  acting  upon  the  clavicle  directly.  We  have  here  an 
illustration  of  the  rule  that  when  it  comes  to  a  test  between  ligaments 
and  bone  the  bone  has  to  yield.  A  force  acting  upon  the  clavicle  will 
almost  surely  break  the  bone  before  it  can  be  torn  from  its  attachments 
to  the  sternum.  When  dislocation  takes  place  it  is  in  one  of  three 
directions — \\z.  forward,  backward,  or  upward. 

Forward  dislocation  is  the  most  common.  The  bone  can  be 
readily  felt  as  a  prominence  in  front  of  the  sternum,  while  an  exam- 
ination of  the  suprasternal  notch  will  show  its  absence  from  the  normal 
position.  The  portion  of  the  sterno-mastoid  muscle  which  is  attached 
to  the  clavicle  is  put  upon  the  stretch,  and  throws  the  patient's  head 
downward  and  forward  ;  movement  of  the  shoulders  forward  is  attended 
with  severe  pain. 

Backward  dislocation  is  also  easily  recognized  by  a  depression 
at  the  normal  position  of  the  end  of  the  bone.  Very  disagreeable 
symptoms  are  produced  if  the  bone  is  sufficiently  displaced  to  cause 
pressure  upon  the  esophagus  or  trachea,  in  the  one  case  causing 
dysphagia,  in  the  other  dyspnea. 

Upward  dislocation  is  the  rarest  of  the  three  forms,  and  is  really 
a  variety  of  the  backward  dislocation,  for  the  bone  is  always  displaced 
backward  as  well  as  upward.  The  bone  fills  up  the  suprasternal  notch 
and  lies  between  the  sternal  portion  of  the  sterno-mastoid  and  the 
sterno-hyoid  muscles. 

The  most  important  of  these  three  is  the  backward  dislocation,  for 
very  prompt  action  may  be  required  to  save  the  patient's  life  when  the 
trachea  is  pressed  upon  by  the  displaced  bone. 

Treatment. — One  method  of  reduction  serves  for  all  of  these  forms 
of  dislocation.  Seat  the  patient  upon  a  low  stool  with  his  back  toward 
you.  Place  his  elbows  close  to  the  sides  and  a  little  in  front  of  the 
median  lateral  line.  Then  with  your  knee  against  his  spine  and  between 
his  scapulae  grasp  the  shoulders  and  bring  them  backw^ard.  If  the  bone 
does  not  slip  into  position  at  once,  direct  manipulation  can  be  employed 
to  aid  in  the  reduction.  When  these  measures  fail,  place  a  large  pad 
in  the  axilla,  and,  using  the  arm  as  a  lever,  press  the  elbow  in  toward 
the  side. 

Reduction,  however,  is  the  smallest  part  of  the  treatment ;  the  dif- 
ficulty is  to  keep  the  bone  in  position  after  it  has  been  replaced.  This 
can  be  readily  understood  when  we  recollect  that  the  articular  surfaces 
are  flat  and  smooth,  the  ligaments  are  usually  ruptured,  while  even  the 
unavoidable  movements  of  respiration  are  sufficient  to  disturb  the  joint. 

In  forivard  dislocation  a  double  figure-of-8  bandage  is  probably  the 
best  appliance.  A  firm  pad  or  a  well-padded  splint  is  placed  between 
the  shoulders  and  the  bandage  passed  over  each  alternately  to  bring 
the  shoulders  back  as  far  as  possible.  Velpeau's  method  is  the  best 
for  dislocation  backward  or  backward  and  7ip%vard.  It  consists  in 
placing  a  pad  in  the  axilla  and  in  drawing  the  elbow  forward  and 
upward  across  the  chest,  so  that  the  hand  of  the  affected  side  can  be 
placed  upon  the  opposite  shoulder.     The  elbow,  forearm,  and  hand  are 


122 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


then  flexed  firmly  in  position  by  strips  of  adhesive  plaster.  In  all  cases 
it  is  necessary  to  place  over  the  end  of  the  bone  a  pad  covered  with 
adhesive  plaster  to  keep  it  from  slipping,  and  hold  it  in  position  by  a 
roller  bandage.  It  is  absolutely  necessary  to  keep  the  arm  rigidly 
immobilized  for  at  least  three  weeks,  after  which  the  bandage  may  be 
to  a  certain  extent  relaxed,  but  no  movement  should  be  allowed  for 
three  or  four  weeks  longer. 

Dislocation  of  the  Acromial  End  (Fig.  47). — The  cause  is  usually 
a  fall  or  a  blow  upon  the  shoulder.    The  direction  is  commonly  upward 

or  upward  and  outward,  so  that  the  end 
of  the  clavicle  is  carried  over  the  end 
of  the  acromion  process.  Reduction  is 
very  easily  effected  by  pressing  the  arm 
upward  and  backward,  when  the  end  of 
the  clavicle  can  be  replaced  by  direct 
manipulation.  Should  crepitus  be  felt 
during  this  movement,  it  may  be  set 
down  as  due  to  a  fracture  of  the  edge 
of  the  articulation.  Should  there  be 
any  doubt  about  the  outer  end  of  the 
clavicle  itself  being  broken,  measure- 
ment of  the  bone  and  comparison  with 
its  fellow  of  the  sound  side  will  settle 
the  question.  It  is  exceedingly  difficult 
to  keep  the  bone  in  position  after  re- 
duction. The  best  method  is  probably 
that  recommended  by  Stimson.  Take 
a  piece  of  strong  adhesive  plaster  three 
inches  wide,  and,  applying  the  middle 
of  it  to  the  point  of  the  elbow  flexed 
to  a  right  angle,  bring  the  ends  up 
over  the  end  of  the  clavicle  before  and 
behind  the  arm,  and  allow  one  to  overlap  the  other  on  the  shoulder. 
The  forearm  is  carried  in  a  sling,  and  the  arm  bound  to  the  side  by  a 
broad  bandage  passing  round  the  body. 

Dislocation  of  the  Sternum. — It  is  difficult  to  distinguish  this 
injury  from  fracture.  It  is  generally  associated  with  fracture  or  dis- 
location of  the  ribs  or  the  costal  cartilages.  When  uncomplicated 
dislocation  takes  place,  it  is  either  the  manubrium  dislocated  from  the 
body  or  the  ensiform  cartilage  from  the  body. 

Diagnosis  is  not  usually  difficult.  The  bone  being  subcutaneous,  a 
change  in  its  outline  can  be  felt.  The  junction  of  the  manubrium  with 
the  body  corresponds  with  the  end  of  the  second  costal  cartilage.  This 
relation  will  be  found  to  have  been  disturbed  in  dislocation. 

Reduction  is  effected  by  requiring  the  patient  to  draw  a  deep 
breath  while  the  fragments  are  directly  pressed  into  position.  Should 
this  fail,  forcible  flexion  of  the  trunk  backward  will  prove  a  valuable 
aid.  Many  cases  have  remained  unreduced  and  little  or  no  incon- 
venience resulted. 

The  cnsifonn  cartilage  may  be  dislocated,  so  that  its  point  is  directed 
forward  or  backward.     It  causes  no  great    inconvenience   as  a  rule, 


Fig.  47. — Upward  dislocation  of  acromial 
end  of  right  clavicle  (Keen  and  White). 


INJURIES  AND  DISEASES   OF  JOINTS. 


123 


although  vomiting  has  been  attributed  to  a  backward  displacement. 
When  the  symptoms  are  severe  enough  to  warrant  interference,  reduc- 
tion can  be  effected  by  drawing  the  cartilage  forward  by  the  fingers  or 
by  a  sharp  hook  inserted  through  the  skin. 

Dislocation  at  the  Shoulder. — In  a  joint  so  freely  movable  and 
so  exposed  to  violence  it  is  not  surprising  that  dislocations  at  the 
shoulder  occur  as  frequently  as  all  other  dislocations  combined.  The 
glenoid  cavity  is  shallow,  and  the  head  of  the  humerus  finds  no  such 
deep  socket  to  rest  in  as  the  head  of  the  femur  finds  in  the  acetabulum. 
The  capsule  is  weak,  loose,  and  easily  torn.  The  joint  is  dependent 
upon  muscles  and  tendons  for  its  support,  while  the  great  length  of  the 
humerus  affords  a  powerful  leverage  which  can  force  the  joint  asunder 
without  difficulty.  The  aspect  of  the  glenoid  fossa  is  forward  and  out- 
ward. The  head  of  the  humerus  can  be  displaced  from  it  in  three 
directions — viz.  forward,  backward,  and  downward,  very  rarely  upward. 

Forward  Dislocations. — Two  varieties  of  this  form  are  recognized : 


Fig.  48. — Kocher's  method  of  reducing  dislocation  of  shoulder :  first  movement,  abduction 

and  external  rotation. 


1.  Subcoracoid,  when  the  bone  has  little  more  than  slipped  off  the 
glenoid  fossa  and  lies  under  the  coracoid  process. 

2.  Subclavicular,  when  the  head  of  the  humerus  has  travelled  farther 
forward  and  lies  beneath  the  clavicle.  Some  authors  give  a  third 
variety,  when  the  head  of  the  bone  lies  a  little  farther  inward  than  the 
coracoid,  and  call  it  intracoracoid. 

Of  the  three  varieties  the  subcoracoid  is  the  most  common.  The 
bone  lies  about  a  finger's  breadth  below  the  coracoid  process.  The 
inner  and  lower  portion  of  the  capsule  is  torn  along  the  edge  of  the 
glenoid  fossa.  Some  of  the  muscles  about  the  joint  may  be  torn,  such 
as  the  subscapularis,  the  supraspinatus,  the  infraspinatus,  and  the  teres 
minor.  Injury  to  the  bones  themselves  is  not  uncommon.  The 
greater  tuberosity  may  be  torn  off,  or  the  head  of  the  humerus  may 
be  bruised  by  forcible  contact  with  the  edge  of  the  glenoid  fossa. 


124 


SURGICAL    DIAGNOSIS  AND    TREATMENT. 


Syiiiptoins. — Following  the  method  of  examination  already  outlined, 
we  observe — 

1.  C/ia)ii^f  of  Con  four- -The  deltoid  is  flattened,  and  the  normal 
fulness  of  the  shoulder  on  its  anterior  and  outer  aspect  is  lost.  The 
injured  elbow  hangs  at  a  little  distance  from  the  side.  The  axis  of  the 
humerus  passes  a  little  in  front  of  the  glenoid  fossa.  The  anterior  fold 
of  the  axilla  is  lowered. 

2.  Abnormal  Position  of  Bony  Prominences. — Instead  of  the  normal 
bony  resistance  below  the  front  and  outside  of  the  acromion,  a  depres- 
sion is  felt,  while  a  well-marked  prominence  is  felt  farther  forward  and 
below  the  coracoid  process.  Press  upon  this  prominence  with  your 
fingers  and  you  will  find  that  it  rotates  with  the  arm. 

3.  Impaired  Mobility. — Active  movement  is  painful  and  perhaps 
impossible.  Passive  movement  is  greatly  limited.  The  arm  can  be 
abducted,  but  cannot  be  so  far  adducted  as  to  allow  the  hand  to  be 


Fig.  49. — Kocher's  method  :  second  movement,  advancement  of  elbow  forward,  upward,  and 
inward,  still  maintaining  external  rotation. 

placed  upon  the  opposite  shoulder  or  the  elbow-  against  the  front  of  the 
chest.  When  measurement  is  desired,  both  arms  should  be  placed  in 
exactly  the  same  position  and  the  tape  stretched  from  the  tip  of  the 
acromion  process  to  the  olecranon. 

When  the  dislocation  is  farther  forward  the  symptoms  are  the  same, 
except  that  the  elbow  is  farther  from  the  side,  and  the  head  of  the 
humerus  is  felt  in  its  new  position — viz.  intracoracoid,  or  subclavicular. 

Treatment. —  i.  Manipulation. — Kocher's  method  (Figs.  48,  49,  50) 
of  manipulation  is  the  best.  Flex  the  elbow  to  a  right  angle  and  press 
it  closely  to  the  side.  Make  external  rotation — i.  e.  turn  the  forearm 
as  far  as  possible  away  from  the  chest,  when  the  head  of  the  humerus 
will  roll  outward  in  front  of  and  below  the  acromion.  Keep  up  the 
external  rotation,  carry  the  elbow  well  forward  and  upward,  rotate  the 
arm  inward,  and  lower  the  elbow.  This  movement  may  be  aided  by 
an  assistant's  directly  manipulating  the  head  of  the  bone  in  the  later 


INJURIES  AND  DISEASES   OF  JOINTS. 


125 


Steps,  or  by  the  use  of  a  band  in  the  axilla  to  draw  the  head  of  the 
humerus   outward. 

2.  Extension  and  Countcr-cxtcnskvi. — An  old  method  of  reducing 
all  forms  of  dislocation  of  the  shoulder  was  to  have  the  patient  placed 
on  a  table,  couch,  or  the  floor,  when  the  surgeon,  removing  his  boot 


Fig.   50. — Kocher's  method   :  rotation  inward,  the  hand  being  carried   toward  the   opposite 

shoulder. 

and  sitting  beside  the  thigh  of  the  patient,  placed  his  heel  in  the  axilla, 
to  make  counter-extension,  while,  grasping  the  wrist  of  the  affected 
limb,  he  steadily  drew  upon  it  until  the  bone  slipped  into  position. 
While  this  method  is  applicable  to  all  dislocations  of  the  shoulder,  it 


Fig.  51. — Reduction  of  dislocation  of  humerus. 

is  not  without  its  disadvantages.  Rupture  of  the  axillary  vessels  has 
more  than  once  occurred.  It  should  never  be  resorted  to  in  the  aged 
or  in  those  whose  arteries  are  diseased.  When  traction  has  to  be 
employed  it  is  better  to  make  it  in  a  direction  at  right  angles  to  the 


126 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


body.  Place  a  folded  sheet  around  the  chest  and  have  an  assistant 
hold  it  firmly  on  the  sound  side.  Then,  grasping  the  injured  limb  by 
the  forearm  and  elbow,  draw  directly  outward,  while  the  assistant 
makes  counter-extension  by  the  sheet  (Fig.  51).  Or,  while  the  patient 
is  l)'ing  down,  make  traction  on  the  arm  until  the  muscles  are  over- 
come ;  then,  using  the  clenched  fist  of  your  disengaged  hand  as  a 
fulcrum,  bring  the  arm  forcibly  in  toward  the  che.st. 

Backward  Dislocation. — Two  dislocations  backward  are  recog- 
nized : 

1.  Subacromial,  when  the  head  of  the  humerus  lies  below  the 
acromion  and  its  anatomical  neck  rests  against  the  edge  of  the  glenoid 
fossa.  ■  This  is  not  very  common. 

2.  Subspinous,  when  the  bone  goes  a  little  farther,  resting  below  the 
spine  of  the  scapula. 

Symptoms. — The  want  of  symmetry  will  be  shown  by  a  loss  of 
fulness  of  the  shoulder  in  front  and  an  increase  behind.  The  head  of 
the  bone  is  generally  felt  without  difficulty,  lying  behind  the  glenoid 
fossa.  The  elbow  lies  close  to  the  side  and  the  arm  is  rotated  inward. 
The  coracoid  and  the  anterior  edge  of  the  acromion  stand  out  with 
unnatural  prominence.  Voluntary  motion  is  lost ;  passive  motion  is 
painful  and  restricted. 

Downward  Dislocation. — This  form  is  rare,  but  when  it  does  occur 
the  symptoms  are  very  characteristic  (Fig.  52).     The  accident  occurs 


Fig.  52. — Subglenoid  dislocation  (Stimson). 

when  the  arm  is  abducted  with  sufficient  force  to  tear  the  capsule,  with 
rotation  or  direct  force  downward,  so  that  the  head  of  the  humerus 
slips  below  the  glenoid  cavity.     Sometimes  the  head  of  the  bone  is 


INJURIES  AND  DISEASES   OE  JOINTS.  12/ 

directly  below  the  glenoid,  but  most  commonly  it  is  below  and  a  little 
in  front.  The  name  subglenoid  is  given  to  both  of  these  varieties.  In 
rare  cases  the  bone  has  slipped  below  the  glenoid  cavity  with  the  arm 
placed  upward  and  close  to  the  side  of  the  head.  This  variety  has 
been  called  hixatio  crccta. 

The  syinptoins  of  subglenoid  dislocation  are  very  similar  to  those  of 
the  subcoracoid,  only  more  pronounced.  A  striking  feature  is  the 
marked  angularity  given  to  the  shoulder  by  the  prominence  of  the 
acromion. 

Treatment. — As  the  bone  lies  upon  or  close  to  the  axillary  vessels, 
great  care  must  be  taken  lest  these  be  injured.  Complete  relaxation 
of  the  muscles  must  be  secured  under  chloroform.  Traction  can  then 
be  made  in  moderate  abduction,  while,  at  the  same  time,  the  bone  can 
be  helped  back  into  position  by  direct  manipulation. 

Upward  dislocation  is  a  curiosity.  Several  cases  have  been 
reported.  One  of  these  occurred  during  an  epileptic  convulsion. 
Another  was  produced  by  a  blow  upon  the  acromion  while  the  arm 
was  raised.  A  fall  upon  the  elbow  caused  the  third.  The  recognition 
of  the  head  of  the  bone  in  its  unnatural  position  is  not  difficult.  Both 
active  and  passive  motions  are  restricted.  The  elbow  is  directed  back- 
ward to  a  slight  degree  and  the  arm  lies  close  to  the  side. 

Errors  in  diagnosis  are  liable  to  occur  by  mistaking  a  dislocation  for — 

1.  Fracture  of  the  neck  of  the  scapula; 

2.  Fracture  of  the  surgical  neck  of  the  humerus ; 

3.  Separation  of  the  greater  tuberosity  of  the  humerus  ; 

4.  Fracture  at  the  anatomical  neck. 

In  all  of  these  the  elbow  can  be  made  to  touch  the  side,  while  in 
dislocation  it  cannot.  Crepitus  is  also  an  unfailing  guide  in  nearly  all. 
Separation  of  the  greater  tuberosity  will  prove  the  most  puzzling,  and 
the  point  will  be  to  decide  between  it  and  subspinous  dislocation.  In 
both  cases  a  tumor  will  be  felt  upon  the  scapula.  It  is  either  the 
detached  tuberosity  or  the  head  of  the  humerus.  In  the  one  case  it 
rotates  with  the  humerus  (dislocation) ;  in  the  other  it  is  small  and  is 
not  affected  by  rotation. 

Dislocations  at  the  Klbow. — This  joint,  being  made  up  of  three 
bones  with  the  two  prominences  of  the  ulna,  is  subject  to  a  great  variety 
of  dislocations.  To  avoid  unnecessary  complications  I  shall  classify 
them  as  follows : 

1.  Common  Dislocations. — {a)  Dislocation  of  the  radius  and  ulna 
together  backward  and  diagonally  backward  and  outward ;  {b)  Dis- 
location of  the  radius  separately. 

2.  Rare  Dislocations. — [a)  Dislocation  of  both  bones  forward,  out- 
ward, or  inward;  {b)  Dislocation  of  the  ulna  alone;  (c)  Dislocation  of 
both  bones  separately,  the  one  being  driven  forward,  the  other  back- 
ward. 

Dislocation  of  both  Radius  and  Ulna. — Examination. — Place  the 
patient  upon  a  chair  and  stand  in  front  of  him.  Grasp  the  two  elbows 
in  the  palms  of  your  hands,  and  place  your  thumbs  on  the  external 
epicondyles,  the  middle  fingers  on  the  internal  epicondyles,  and  the  tips 
of  the  fore  fingers  on  the  tips  of  the  olecranon  processes.  When  the 
joint  is  extended  these  three  points  should  form  a  line  transversely  to 


128 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


the  axis  of  the  arm.  When  the  elbow  is  bent  the  tip  of  the  olecranon 
sinks  below  the  epicondyles.  Any  disturbance  of  these  relations  will 
indicate  that  something  is  wrong  with  the  joint — either  dislocation  or 
fracture. 

Backivard  Dislocation  of  Both  Bones  (Fig.  53). — In  this  case  the 
olecranon  is  carried  far  back,  and  the  distance  between  it  and  the  epi- 
condyles is  increased.  The  head  of  the 
radius  is  felt  at  the  back  of  the  outer  con- 
dyle. The  greater  sigmoid  notch  of  the 
ulna  can  be  felt  at  the  back  of  the  joint, 
and  the  tendon  of  the  triceps  stands  out 
prominently.  Passive  flexion  and  extension 
are  greatly  restricted.  There  is  usually 
considerable  swelling  and  pain. 

Treatmeiit. — While  an  assistant  holds 
the  lower  end  of  the  humerus,  and  at  the 
same  time  pushes  it  slightly  backward, 
make  traction  upon  the  forearm  in  the 
extended  position.  This  is  generally  suf- 
ficient to  overcome  the  action  of  the  mus- 
cles and  to  bring  the  coronoid  process  of 
the  ulna  in  front  of  the  humerus,  where  it 
belongs.  A  time  -  honored  plan,  often 
spoken  of  as  Sir  Astley  Cooper's  method, 
is  to  place  your  knee  on  the  bend  of  the 
elbow,  and,  grasping  the  wrist,  flex  the 
joint  strongly  over  the  knee  as  a  fulcrum. 
If  any  difficulty  is  experienced  in  either  of 
these  methods,  the  patient  should  be  anes- 
thetized. 

After  reduction  the  limb  should  be  immobilized  for  about  three 
weeks.  During  this  time  massage  will  be  found  useful,  but  passive 
motion  is  unnecessary,  and  may  even  prove  harmful.  Any  stiffness  of 
the  joint  which  remains  after  removing  the  splints  rapidly  disappears 
under  exercise  of  the  limb. 

Compound  dislocation  at  the  elbow  is  a  serious  matter.  When 
there  is  much  injury  to  the  end  of  one  or  more  of  the  bones,  the 
destroyed  portions  must  be  removed  as  an  atypical  resection  ;  other- 
wise reduction  should  be  effected,  thorough  drainage  established,  and 
the  principles  carried  out  which  are  applicable  to  wounds  of  joints. 

Forxvard  Dislocation  of  Both  Bones. — This  accident  is  always  the 
result  of  great  violence,  and  the  injury  is  almost  sure  to  be  complicated 
with  fracture  of  the  olecranon.  In  this  variety  the  olecranon  lies  in 
front  of  the  humerus  or  may  find  its  way  into  the  coronoid  fossa.  The 
arm  is  bent  to  nearly  a  right  angle,  and  the  forearm  is  supinated. 
When  the  normal  position  of  the  olecranon  is  examined,  there  will  be 
found  a  flat,  broad  surface  caused  by  the  lower  end  of  the  humerus. 
When  the  olecranon  is  broken  off,  it  is  retained  on  the  posterior  aspect 
of  the  joint,  but  drawn  upward  by  the  triceps.  Fortunately,  this  dis- 
location  is  rare. 

Treatment. — The  obstacle  to  reduction  is  the  olecranon,  which,  if 


Fig.  53. — Dislocation  of  the  elbow 
backward  (Stimson). 


INJURIES  AND  DISEASES   OF  JOINTS. 


129 


not  fractured,  must  be  disengaged  from  the  coronoid  fossa  and  made  to 
slip  over  the  articular  end  of  the  humerus  to  its  normal  position. 
After  thoroughly  relaxing  the  muscles  under  an  anesthetic,  hold  the 
forearm  at  a  right  angle,  make  extension  from  the  wrist  and  counter- 
extension  from  the  lower  end  of  the  humerus.  When  the  olecranon  is 
disengaged  from  the  coronoid  fossa  make  direct  pressure  downward 
upon  the  anterior  aspect  of  the  forearm,  close  to  the  elbow.  Examine 
carefully,  after  reduction,  to  make  sure  that  the  head  of  the  radius  is  in 
its  proper  position. 

Imvard  Dislocation  of  Both  Bones. — This  is  an  incomplete  dislo- 
cation. The  olecranon  will  be  found  out  of  its  normal  position  and 
toward  the  inner  aspect  of  the  joint.  The  external  condyle  will  be 
more  prominent,  and  the  internal  less  prominent,  than  on  the  sound 
side.  When  there  is  not  much  swelling  the  head  of  the  radius 
can  be  detected  on  the  articular  surface  of  the  humerus  about  its, 
middle. 

Treatment. — ]\Iake  extension  and  counter-extension  in  the  flexed 
position  (combined  with  direct  pressure),  gradually  bringing  the  arm 
into  the  position  of  full  extension. 

Ontzvard  Dislocation  of  Both  Bones. — The  inner  condyle  of  the 
humerus  is  naturally  more  prominent  than  the  external,  but  in  this 
accident  the  prominence  is  greatly  exaggerated,  while  the  external 
condyle  can  with  difficulty  be  felt.  The  hand  is  pronated,  and  the 
elbow  bent  to  an  angle  of  about 
120°  (Fig.  54). 

Treatment.  —  Extension  and 
counter-extension  with  direct  lat- 
eral pressure.. 

The  very  rare  deformity  known 
as  divergent  dislocation,  in  which 
the  ulna  and  radius  are  dislocated 
separately,  needs  no  special  men- 
tion. 

Dislocation  of  the  Radius 
Alone. — This  can  take  place  in 
five  directions  —  forward,  back- 
ward, outward,  inward,  and  down- 
ward. 

Foriuai'd  dislocation  is  recog- 
nized by  finding  a  tumor  in  front 
of  the  humerus  which  rotates  with 
the  elbow,  while  a  depression  is 
found  in  the  normal  position  of 
the  head  of  the  radius  at  the  ex- 
ternal condyle.  Supination  of  the 
hand  causes  pain,  while  pronation 
is  not  impaired.  The  arm  can  be 
extended  without  difficulty,  but 
common  complication  of  this  injury  is  fracture  of  the  shaft  of  the  ulna. 

Treatment. — In  some  cases  reduction  is  difficult  or  even  impossible, 
while    in  others  it    proves  very  simple.     Extend    the  forearm,   make 
9 


Fig.  54. — Outward  (supra-epicondylar)  dislo- 
cation of  the  elbow  (Keen  and  White). 

flexed   only  to   a  right  angle.      A 


130  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

steady  adduction  to  disengage  the  head  of  the  bone,  and  then  by  direct 
pressure  force  it  into  its  proper  position. 

Backzvard  (dislocation  of  the  radius  is  rare.  The  tumor  in  this  case 
is  felt  behind  the  humerus,  and  moves  with  rotation  of  the  radius. 
When  the  ulna  is  fractured  the  tendency  is  for  the  radius  to  be  pushed 
upward,  the  forearm  at  the  same  time  being  abducted.  Reduction  is 
effected  by  direct  pressure  upon  the  head  of  the  radius. 

Oittzcard  dislocation  is  exceedingly  rare,  and  is  readily  diagnosed  by 
the  position  of  the  head  of  the  bone  at  the  outer  side  of  the  elbow. 

Inward  dislocation  cannot  occur  without  displacement  of  the  ulna 
as  well. 

Dozvnu'ard  dislocation,  an  accident  of  young,  loose-jointed  children, 
is  caused  by  forcibly  drawing  upon  the  hand  of  a  child  of  three  years 
of  age  or  less.  After  a  jerk  the  child  cries  with  pain  and  cannot  use 
the  arm.  The  limb  hangs  by  the  side  with  the  forearm  slightly  pro- 
nated.  On  examination  there  is  tenderness  over  the  head  of  the  radius, 
and  the  bone  may  be  felt  to  be  displaced  downward.  It  is  supposed  to 
be  below  the  orbicular  ligament. 

Treatment. — Steadily  supinate  the  arm,  when  a  slight  click  will  be 
felt  and  no  more  inconvenience  will  be  experienced. 

Dislocation  of  the  Ulna  Alone. — This  is  a  rare  accident.  It 
cannot  be  displaced  forward  without  fracture  of  the  olecranon.  When 
dislocated  backward  the  marked  prominence  of  the  olecranon  behind 
and  the  trochlea  in  front  leaves  no  room  for  doubt. 

Old,  unreduced  dislocations  at  the  elbow  are  difficult  to  treat.  If 
the  patient  is  young  and  there  has  been  disturbance  of  the  periosteum 
at  the  time  of  the  injury,  new  bone  has  probably  been  thrown  out 
which  forms  an  insuperable  barrier  to  the  movements  of  the  joint. 
The  displaced  olecranon  becomes  firmly  bound  down  by  adhesions  to 
the  posterior  surfaces  of  the  humerus,  and  should  the  limb  become 
fixed  in  an  extended  position,  it  is  almost  useless  to  the  patient. 
Three  courses  are  open  to  the  surgeon  : 

1.  Forcible  flexion  of  the  joint,  with  or  without  fracture  of  the 
olecranon. 

2.  Open  arthrotomy,  with  division  of  all  the  tissues  which  prevent 
movement. 

3.  Resection  of  the  joint. 

Dislocation  at  the  Wrist -joint. — Examination  of  the  Wrist  and 
Hand. — The  bones  of  the  wrist  and  hand  being  subcutaneous,  any 
irregularity  due  to  displacement  or  fracture  is  readily  detected  by  the  eye 
or  palpated  by  the  fingers.  Run  your  fingers  over  the  dorsum  of  the 
carpal,  metacarpal,  and  phalangeal  bones  and  note  any  irregularity. 
Grasp  the  extremities  of  each  bone,  and  ascertain  whether  there  be 
movement  or  crepitus. 

Dislocation  of  the  Lower  End  of  the  Ulna. — This  can  occur 
backward  or  forward.  In  either  case  the  end  of  the  ulna  stands  out 
prominently,  can  be  recognized  in  its  new  position,  and  frequently  over- 
laps the  end  of  the  radius. 

Direct  pressure  is  sufficient  to  replace  the  bone. 

Dislocation  of  the  carpus  from  the  radius.  This  may  take  place 
in  four  directions — forward,  backward,  outward,  and  inward. 


INJURIES  AND  DISEASES   OF  JOINTS.  I3I 

These  deformities  present  no  difificulties  in  their  diagnosis.  It  must 
be  borne  in  mind  that  dislocation  at  the  wrist  is  very  rare  compared 
with  two  other  injuries  for  which  it  is  Hable  to  be  mistaken.  These  are 
Colles's  fracture  and  sprain.  Careful  attention  to  the  symptoms  of 
Colles's  fracture — the  silver-fork  appearance,  the  position  of  the  styloid 
process  of  the  radius,  and  its  relation  to  the  ulna — will  leave  no  room 
for  doubt.  In  this  fracture  the  styloid  process  is  below  the  prominence 
on  the  back  of  the  wrist,  while  in  dislocation  of  the  carpus  forward  the 
bones  form  a  rounded  prominence  on  the  front  of  the  wrist,  behind 
which  is  a  sharply-defined  line  representing  the  lower  end  of  the  radius. 

Of  the  carpal  bones  the  semilunar  is  the  one  which  is  most  fre- 
quently dislocated  singly.  The  displacement  is  forward.  Except  when 
swelling  is  great  the  deformity  is  easily  recognized. 

Treatjnent  consists  in  replacing  the  bone  by  direct  pressure. 

Dislocation  at  the  Carpo-metacarpal  Joints. — The  most  frequent 
and  the  most  important  of  these  is  found  at  the  base  of  the  metacarpal 
bone  of  the  thumb.  The  direction  is  backward,  and  the  luxation  is 
frequently  incomplete.  The  head  of  the  bone  can  be  felt  between  the 
tendons  of  the  extensor  primi  and  secundi  internodii  pollicis.  Reduc- 
tion is  readily  effected  by  extension,  counter-extension,  and  direct  pres- 
sure. Immobilization  should  be  maintained  for  one  or  two  weeks,  as 
the  displacement  is  liable  to   return. 

Metacarpo-phalangeal  Dislocation. — This  is  most  frequently  seen 
in  the  thumb.  Small  and  insignificant  as  this  joint  appears,  the  difficulty 
of  reducing  a  dislocation  here  is  often  very  great,  owing  to  the  inter- 
position of  the  anterior  ligament  with  the  sesamoid  bones. 

The  phalanx  is  generally  displaced  backward  and  overlaps  the 
metacarpal  bone.  A  very  troublesome  complication  of  this  injury 
arises  when  the  glenoid  ligament  is  turned  upward  and  lies  between 
the  phalanx  and  the  metacarpal  bone.  This  may  occur  during  attempts 
at  reduction. 

Treatment. — Make  strong  extension  and  press  the  thumb  downward 
until  the  anterior  edge  of  the  base  of  the  phalanx  overlaps  the  lower 
end  of  the  metacarpal  bone.  Then  flex  the  thumb,  and  the  bone  slips 
into  its  place.  Sometimes  the  glenoid  ligament  and  the  heads  of  the 
flexor  brevis  form  a  sort  of  button-hole  through  which  the  end  of  the 
phalanx  must  be  manipulated.  This  can  be  done  by  direct  pressure 
combined  with  rotation,  first  to  one  side  and  then  to  the  other. 

Dislocations  of  the  Phalanges. — These  offer  no  difficulty  in  diag- 
nosis and  seldom  prove  obstinate  in  reduction.  To  obtain  a  grasp  upon 
them  various  devices  have  been  resorted  to,  of  which  the  best  and 
readiest  is  the  clove  hitch. 

Dislocations  at  the  Hip-joint. — Examination  of  the  Hip. — The 
patient,  divested  of  ordinary  clothing,  should  be  placed  upon  a  table  or 
firm  mattress.  In  the  case  of  females  a  thin  night-dress  or  sheet  cover- 
ing the  body  need  not  interfere  with  the  examination  and  renders  the 
ordeal  less  embarrassing.  See  that  the  body  lies  perfectly  straight,  and 
that  a  line  from  one  anterior  superior  spine  of  the  ilium  to  the  other 
lies  at  right  angles  to  a  line  from  the  ensiform  cartilage  to  the  sym- 
physis pubis. 

I.  Inspection. — With  the  spine  resting  its  whole  length  upon  the 


132  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

table  observe  whether  one  or  both  knees  are  flexed.  The  knee  being 
pressed  down  upon  the  table,  observe  if  the  spine  becomes  lordosed 
(arched  forward).  If  this  occur,  it  is  strong  evidence  of  disease  of  the 
joint,  of  psoas  abscess,  of  sacro-iliac  disease  when  complicated  with 
psoas  abscess,  or  of  inflamed  bursa;  beneath  the  psoas. 

Does  the  suspected  limb  lie  parallel  to  its  fellow  ?  The  thighs  are 
normally  directed  inward  in  women,  slightly  so  in  men.  If  the  thigh  is 
abducted,  it  is  evidence  of  the  early  stage  of  coxitis  or  of  .synovitis  of 
the  hip. 

Adduction  of  the  thigh  points  to  dislocation  on  the  dorsum  ilii  and 
to  the  later  stages  of  joint-disease. 

Observe  whether  the  limb  is  rotated  in  or  out.  Eversion  occurs 
in  fracture  of  the  neck  of  the  femur  or  when  the  synovial  cavity  is  dis- 
tended, as  in  synovitis,  or  when  there  is  tension  of  the  psoas  and  iliacus 
muscles  as  in  abscess.  Inversion  is  evidence  of  dislocation  or  of  the 
later  stages  of  morbus  coxce. 

2.  Measurement. — The  limb  can  be  best  measured  from  the  anterior 
superior  spine  of  the  ilium  to  the  external  malleolus.  Shortening  indi- 
cates at  least  two  of  the  forms  of  dislocation — on  the  dorsum  ilii  and 
into  the  sciatic  notch.  It  is  also  a  sign  of  fracture  of  the  neck  of  the 
femur  and  of  advanced  hip-disease.  Do  not  be  misled  by  the  apparent 
lengthening  of  a  limb.     This  is  due  to  a  simple  tilting  of  the  pelvis. 

3.  Mobility  of  the  Joint. — Grasp  the  knee  with  one  hand,  place  the 
other  upon  the  outer  side  of  the  pelvis,  and  put  the  joint  through  the 
several  movements  of  flexion,  extension,  adduction,  abduction,  and 
rotation.  Observe  carefully  whether  the  pelvis  moves  with  the 
femur ;  if  so,  whether  this  is  due  to  bony  ankylosis  or  to  rigidity 
of  muscles,  and  whether  the  movements  are  attended  with  pain.  The 
patient's  attention  should  be  diverted,  otherwise  it  will  be  difficult  ta 
determine  how  much  muscular  rigidity  is  due  to  his  fear  of  being  hurt. 
When  doubt  on  this  point  still  remains,  give  an  anesthetic,  and  if 
rigidity  passes  off  you  may  know'  it  was  due  to  muscular  contrac- 
tion. 

4.  Exami7iation  of  the  Bones. — Begin  with  the  trochanter  ;  compare 
the  two  sides,  and  then,  applying  the  palm  of  the  hand,  press  inward 
firmly  and  gradually  against  the  neck  of  the  femur.  Pain  or  tenderness 
under  this  test  is  evidence  of  inflammation  of  the  neck  or  head  of  the 
femur.  The  head  of  the  bone  may  be  sought  for  on  the  dorsum  ilii, 
the  buttock,  or  near  the  pubis.  Grasp  the  iliac  crests  and  press  them 
toward  or  apart  from  each  other.  Pain  felt  in  these  movements  should 
direct  attention  to  inflammation  in  the  sacro-iliac  joint. 

Dislocations  at  the  hip  can  never  be  intelligently  studied  without 
first  having  mastered  two  small  and  apparently  insignificant  structures 
that  enter  into  the  formation  of  the  joint.  One  of  these  is  the  Y-liga- 
ment,  so  called,  and  the  other  is  the  obturator  internus  muscle. 
Before  Prof  Henry  J.  Bigelow  of  Boston  revolutionized  the  treatment 
of  dislocation  at  the  hip  the  great  obstacle  to  reduction  was  supposed 
to  be  the  resistance  of  the  powerful  muscles  about  the  joint.  Dr. 
Bigelow  cut  away  all  the  other  muscles,  and  still  found  that  these  two 
structures,  the  Y-ligament  and  the  obturator  internus  muscle,  were 
sufficient  to  produce  all  the  varieties  of  luxation  of  this  joint,  and  also- 


INJURIES  AND  DISEASES   OF  JOINTS. 


133 


to  constitute  the  obstacles  which  prevent  the  return  of  the  bone  to  the 
acetabulum. 

What  is  the  Y-ligament  ?  It  is  a  portion  of  the  capsular  ligament 
which  is  thick  and  strong,  and  remains  untorn  when  the  head  of  the 
bone  makes  a  rent  in  any  other  part  of  the  capsule.  The  capsular 
ligament  is  a  sort  of  tube  surrounding  the  joint.  It  arises  from  the 
circumference  of  the  acetabulum  and  the  parts  surrounding,  and  is 
inserted  near  the  junction  of  the  neck  of  the  femur  with  the  trochanter. 
The  human  being  walks  erect,  and  naturally  a  severe  jolt  transmitted 
to  the  joint,  as  in  jumping  from  a  height,  is  likely  to  dislocate  the  bone 
upward.  To  prevent  this  the  capsular  ligament  is  much  thicker  and 
stronger  on  that  side,  and  forms  a  powerful  band  which  helps  to  keep 
the  joint  in  position.  This  part  of  the  capsule,  which  goes  under  the 
various  names  of  the  "  Y-ligament,"  the  "  ilio-femoral   ligament,"  and 

"  Bertin's  ligament,"  arises  from  the 
anterior  inferior  spinous  process  of  the 
ilium,  and  from  the  bone  below  as  far 


Fig.  55. — The  Y-ligament. 


Fig.  56. — The  obturator  internus  muscle 


as  the  border  of  the  acetabulum.  This  dense  band,  sometimes  a  quarter 
of  an  inch  in  thickness,  passes  down  toward  the  great  trochanter,  where 
it  divides  into  two  "branches,  thus  forming  an  inverted  letter  Y.  One  of 
these  branches  is  inserted  into  the  anterior  and  superior  part  of  the  great 
trochanter.  The  other  goes  farther  down,  and  is  inserted  into  the  femur 
close  to  the  lesser  trochanter  (Fig.  55). 

Bear  in  mind,  that  in  all  dislocations  at  the  hip  this  ligament  remains 
untorn,  while  every  other  structure  may  be  lacerated.  By  its  tension  is 
determined  the  different  positions  which  characterize  the  deformity,  such 
as  flexion,  inversion,  eversion,  adduction,  or  abduction  of  the  limb. 

TJic  obturator  intcrmis  muscle,  the  other  structure  which  plays  an  im- 
portant part  in  some  dislocations,  arises  inside  the  pelvis  from  the  inner 
surface  of  the  obturator  membrane    and  from   the  bony  edge  of  the 


134 


SURGICAL    DIAGNOSIS  AND    TREATMENT. 


foramen.  Its  fibers  converge  into  a  tendon  which  passes  toward  the 
lesser  sciatic  notch,  where  it  winds  around  a  trochlear  surface,  and  is 
inserted  into  the  upper  border  of  the  great  trochanter  in  front  of  the 
pyriforniis  (Fig.   56). 

Dislocations  at  the  hip-joint  are  four  in  number — two  back- 
ward and  two  forward. 

If  a  dislocation  is  backward,  it  is  either  on  the  dorsum  ilii  or  into 
the  sciatic  notch  ;  if  forward,  it  is  either  on  the  obturator  foramen  or 
on    the  pubis. 

Dislocation  upon  the  Dorsum  Ihi. — Supposing  a  person  to  fall 
from  a  height,  his  abducted  knee  first  striking  the  ground  and  with  the 
body  bent  forward,  the  force  will  come  upon  the  posterior  wall  of  the 
capsular  ligament  and  the  ligamentum  teres,  both  of  which  will  yield 
readily.  The  limb,  being  abducted,  loses  the  support  of  the  great  mus- 
cles, and  the  head  of  the  femur  slips  out  of  its  socket  backward.  It 
must  land  in  one  of  two  places,  the  sciatic  notch  or  the  dorsum  ilii. 
The  same  accident  is  liable  to  occur  when  a  person  is  bending  forward 
and  a  heavy  body  falls  upon  his  back  or  hips.  While  the  bone  is  slip- 
ping backward  the  Y-ligament  becomes  tense,  and  would  prevent  the 

displacement  but  for  one  thing.  The  femur 
rotates  inward,  so  that,  w  hile  the  Y-ligament 
holds  the  trochanter  firmly  enough,  the  head 
of  the  bone  slips  outward.  This  accounts  for 
one  of  the  characteristic  signs — viz.  inver- 
sion of  the  foot.  The  head  of  the  femur 
being  thrown  backward  and  the  Y-ligament 
still  on  the  stretch,  the  knee  is  of  necessity 
thrown  forward ;  both  of  these  deformities 
continue  until  the  luxation  is  reduced.  The 
capsule  is  torn  at  its  posterior  part,  and  also 
some  of  the  muscles  about  the  joint,  such 
as  the  quadratus  femoris,  the  obturator  in- 
ternus  and  externus,  and  the  pyriformis. 

Symptoms. — The  limb  is  shortened  from 
one  to  two  inches.  The  knee  is  directed  to 
the  sound  limb,  and  the  toes  lie  upon  the 
instep  of  the  opposite  foot.  The  head  of  the 
bone  can,  in  some  cases,  be  felt  in  its  new 
position  on  the  dorsum  ilii  (Fig.  57). 

Dislocation  into  the  Sciatic  Notch. — 
This  is  also  a  backward  dislocation,  and 
presents  the  same  symptoms  as  the  iliac 
variety,  only  to  a  less  marked  degree. 
The  shortening  is  not  more  than  three- 
quarters  of  an  inch  to  an  inch.  Inversion 
of  the  toes  and  adduction  of  the  thigh  are 
also  present,  but  less  marked  than  in  the 
former  case.  The  toes  of  the  injured  side  rest  upon  the  ball  of  the 
great  toe  of  the  opposite  foot.  There  is  little  difficulty  in  diagnosing 
these  two  dislocations  from  one  another,  nor  would  a  failure  to  do  so 
result  in  any  serious  consequences,  as  the  treatment  is  the  same.     The 


Fig.  57. — Dislocation  on  dorsum  ilii. 


INJURIES  AND   DISEASES  OF  JOINTS. 


135 


mistake  most  likely  to  be  made  is  to  fail  to  distinguish  between  sciatic 
dislocation  and  fracture  of  the  neck  of  the  femur  with  inversion  of 
the  foot.  In  most  cases  of  fracture  there  is  eversion  of  the  foot,  but 
with  impaction  there  may  be  inversion  ;  hence  the  necessity  for  careful 
examination.     The  following  are  the  important  differences  : 


Sciatic  Dislocation. 


Frequent  in  middle  life. 
Result  of  violence. 


Slight. 


Absent. 


Impaired. 


Fracture  of  Femur  with  Inversion. 
History. 

An  injury  of  old  age. 
Often  slight  violence. 

Shortening. 

Well  marked. 

Crepitus. 

Present  unless  impacted. 

Mobility  of  Limb. 

Often  increased. 


Inversion  of  Foot. 
Inversion  is  persistent  until  the  dislocation  is     The  foot  may  at  any  time  become  everted  by 
reduced.  relief  of  the  impaction. 

Tuvior. 

An   abnormal   tumor   may   be    obscurely   felt     The  upper  fragment  often  fails  to  move  with 
behind  the  acetabulum,  which  moves  with         the  rest  of  the  femur, 
the  rotation  of  the  thigh. 

Dorsal  Dislocation  with  Eversion. — In  the  rare  instances  in  which 
this  form  occurs  the  outer  branch  of  the  Y-ligament  ruptures,  and 
allows  the  head  of  the  femur  to  slip  inward,  thus  causing  eversion  of 
the  foot,  instead  of  inversion,  as  in  the  ordinary  form  of  the  luxation. 

Treatment  of  Backiuard  Dislocations. — Prof  Bigelow's  reduction  by 
manipulation  is  a  great  improvement  on  the  older  methods  (Fig.  58). 
The  patient  lies  on  his  back  upon  a  low 
table,  completely  anesthetized.  Grasp  the 
ankle  of  the  dislocated  limb  with  one  hand 
and  the  leg  below  the  knee  with  the  other. 
Flex  the  leg  on  the  thigh,  and  the  thigh 
upon  the  abdomen  until  it  forms  a  right 
angle  with  the  surface  of  the  table.  Adduct 
the  knee  until  it  is  carried  over  the  middle 
of  the  sound  thigh.  Next  cause  the  knee 
to  describe  a  circle  outward  and  downward 
until  the  leg  is  brought  to  the  table  and  lies 
extended  by  the  side  of  its  fellow.  What 
has  been  done  in  this  maneuver  ?  By 
flexion  of  the  thigh  you  have  relaxed  the 
Y-ligament.  When  you  adducted  the  thigh 
with  outward  rotation  the  head  of  the  bone 
was  lifted  over  the  edge  of  the  acetabulum 
and  it  dropped  into  its  normal  position. 

Backward  Dislocations  below  the  Ten- 
don of  the  Obturator  Internus. — If  you   examine   Fig.   56,  you  will 


Fig.  58. — Reduction  of  dislo- 
cation on  dorsum  ilii  (after  Bige- 
low), 


136 


SURGICAL    DIAGNOSIS  AND    TREATMENT. 


SCO  the  position  of  the  obturator  internus  muscle.  In  the  ordinary 
backward  dislocations  of  the  femur  the  head  of  the  bone  passes  above 
the  muscle.  In  the  variety  of  dorsal  dislocation  which  we  now  have 
to  consider  it  passes  bcloiv  the  muscle ;  and  this  is  the  important  part 
which  the  obturator  internus  plays  in  luxation  of  the  hip.  The  bone, 
having  slipped  out  of  its  socket  and  passed  below  the  obturator  inter- 
nus tendon,  does  so  while  the  thigh  is  in  a  flexed  position.  As  soon, 
however,  as  the  thigh  is  brought  down  from  this  to  a  straight  position, 
the  head  of  the  bone,  being  firmly  held  at  the  trochanter  by  the  Y-liga- 
ment,  slips  upward  over  the  tendon,  which  now  winds  tightly  around* 
the  neck  of  the  ferrjur  between  the  head  and  the  acetabulum.  No 
wonder  the  old  surgeons  pulled  and  dragged  with  pulleys  until  they 
either  caused  something  to  break  or  gave  up  the  fight  and  called  the 
case  one  of  "  irreducible  dislocation." 

Treatment. — The  patient  lying  on  his  back,  proceed  as  follows  : 
First  movement :    Carry  the  knee  across  the  opposite  thigh  to  a 
position  of  extreme  adduction. 

Second  movement :  Sweep  it  upward  horizontally  toward  the  abdo- 
men. This  will  allow  the  head  of  the  bone  to  come  down  below  the 
tendon. 

Third  movement :  Raise  the  thigh  to  a  vertical  position,  and  the 
bone,  disengaged  from  its  entanglement  with  the  obturator  tendon,  will 
lie  in  the  position  of  an  ordinary  backward  dislocation.  From  this 
point  reduction  can  be  effected  as  described  under  backward  dislo- 
cation— viz.  adduction  until  the  knee  is  carried  over  the  middle  of  the 
sound  thigh.  Then  describe  a  circle  upward,  out- 
ward, and  downward  until  the  leg  is  brought  to 
the  table. 

For-ward  Dislocations. — These  have  a  direc- 
tion downward  and  inward.  Two  dislocations  are 
found  under  this  heading  : 

I.  Into  the  Obturator  Foramen. — This  acci- 
dent occurs  while  the  person,  standing  with  the 
thigh  abducted  and  flexed,  receives  a  blow  upon 
the  back  of  the  pelvis,  or  it  can  be  caused  by 
forced  abduction  alone.  The  Y-ligament  remains 
untorn,  and,  as  the  head  of  the  femur  is  driven 
forward  and  inward,  the  thigh  is  flexed  and  ab- 
ducted. The  symptoms  are  very  characteristic. 
The  patient  stands  with  the  injured  limb  a  little 
in  advance  of  its  fellow.  There  is  apparent  length- 
ening, but  this  is  due  to  a  tilting  of  the  pelvis. 
Measurement  may  even  reveal  a  slight  amount  of 
shortening.  The  hip  is  flattened,  the  adductors 
tense,  and  the  head  of  the  bone  in  some  cases  can 
be  felt  on  deep  pressure  (Fig.  59). 

Treattnent. — Place  a  towel  around    the    upper 
end  of  the  thigh,  and,  while  an  assistant  drawls  out- 
ward upon  it  at  right  angles  to  the  middle  line  of  the  body,  make  alter- 
nate flexion  and  extension  of  the  thigh  upon  the  body.     This  is  the 
simplest  method,  and  probably  the  best.     By  it  the  wTiter  succeeded  in 


Fig.    59.— Thyroid   dis 
location. 


INJURIES  AND  DISEASES   OF  JOINTS. 


137 


slip  only  a  little  past  the 
This  variety  is  therefore 


two  cases^ — one  at  the  end  of  eight  weeks,  and  the  other  after  the  expi- 
ration of  three  months. 

Another  method  is  as  follows  :  Flex  the  thigh  to  a  right  angle, 
adduct  and  make  traction  at  the  same  time,  and  then  rotate  inw'ard 
while  lowering  the  knee  (Fig.  60). 

2.  On  the  Perineum. — The  bone  has  to 
obturator  foramen  to  lodge  in  the  perineum. 
an  exaggerated  form  of  the  preceding  dis- 
placement. Flexion  and  adduction  are  now 
more  marked,  and  there  may  be  a  slight 
degree  of  shortening. 

Pubic  Dislocation. — This  occurs  usually 
while  the  limb  is  in  a  position  of  over- 
extension, or  it  may  be  caused  by  a  fall  upon 
the  knees  or  feet.  The  bone  can  occupy  one 
of  several  positions  in  the  neighborhood  of 
the  pubis,  but  the  most  common  is  the  ilio- 
pectineal  eminence.    The  head  of  the  femur 


Fig.  60. — Reduction  of  dislocation  into  the  thyroid 
foramen  (after  Bigelow), 


Fig.  61. — Dislocation  of  head    of  femur 
upon  the  pubes  (after  Hamilton). 


cannot  only  be  felt,  but  even  be  distinctly  seen,  in  its  unnatural  position. 
The  toes  point  outward.  There  is  flexion  of  the  thigh,  and  if  the  knee 
be  pressed  down  upon  the  table  the  spine  will  be  found  to  arch  upward 
in  compensation.  In  backward  dislocation  the  injured  thigh  lies  across 
the  opposite  limb,  but  here  the  reverse  is  true,  and  it  takes  a  direction 
outward  (Fig.  61). 

The  injury  most  liable  to  be  mistaken  for  this  luxation  is  fracture  of 
the  neck  of  the  femur,  yet  there  need  be  no  difficulty  in  settling  the 
question.  If  the  patient  be  anesthetized,  the  outward  rotation  can  be 
rectified  in  fracture,  but  immobility  will  be  found  in  dislocation. 
There  is  shortening  in  fracture  which  can  be  removed  by  traction. 
In  almost  every  case  the  head  of  the  bone  can  be  distinctly  felt  in 
dislocation. 

Treatment. — First  movement :  Flex  the  thigh.  Second  movement : 
Abduct  the  thigh  and  make  traction  in  the  line  of  the  axis  of  the  femur, 


138  SURGICAL    DIAGNOSIS  AND    TREATMENT 

while  an  assistant  at  the  same  time  presses  the  head  downward  and 
outward  toward  the  acetabukim. 

Rare  Forms  of  Dislocation. — Of  all  cases  of  dislocation  at  the  hip- 
joint,  the  dorsal  luxations  occur  in  50  per  cent.,  the  ischiatic  in  30  per 
cent.,  the  obturator  in  1 1  per  cent.,  the  pubic  in  7  per  cent.  This  leaves 
2  per  cent,  of  cases  in  which  the  bone  is  found  outside  any  of  these 
regions.  One  of  these  is  downward  upon  the  tuberosity  of  the  ischium. 
It  is  very  rare,  and  when  it  does  occur  the  displacement  is  often  changed 
into  one  of  the  more  common  varieties.  Thus  the  bone  can  slip  upward 
and  backward,  becoming  a  dorsal,  or  forward  by  adduction  and  ever- 
sion,  forming  a  dislocation  into  the  obturator  foramen. 

Treatment. — Flex  the  thigh  and  then  make  traction. 

Another  rare  luxation  is  directly  upward  (supracotyloid).  Only  a 
few  cases  of  this  kind  have  been  reported.  The  symptoms  are  eversion 
with  abduction.  The  trochanter  is  moved  upward  and  backward,  and 
the  head  of  the  bone  can  be  felt  on  deep  pressure. 

Diagnosis  between  Contusion  over  the  Great  Trochanter  a}id  Dis- 
location at  the  Hip-joi)it. — A  person  suffering  from  a  fall  or  a  blow 
upon  the  great  trochanter  may  present  some  symptoms  which  are 
difficult  to  distinguish  from  dislocation.  The  pain  may  be  so  great  as 
to  render  movement  impossible  ;  the  limb  may  be  apparently  shortened, 
owing  to  the  patient's  trying  to  find  the  easiest  position.  When  there 
is  doubt  an  anesthetic  will  make  diagnosis  easy.  Motion  is  then  free 
and  normal  if  the  injury  is  only  a  bruise,  but  is  restricted  in  the  case  of 
a  dislocation.  Measurement  will  show  a  change  in  the  length  of  the 
limb  in  the  case  of  a  dislocation,  but  none  when  the  injury  is  a  bruise. 
Palpation  will  settle  the  position  of  the  head  of  the  bone. 

Congenital  Dislocation  of  the  Hip. — This  is,  in  the  majority  of 
cases,  due  to  arrested  development,  and  the  displacement  is  most  com- 
monly upward  upon  the  dorsum  ilii.  In  some  instances  the  head  of 
the  femur  is  normal,  but  it  is  quite  common  to  find  the  neck  shorter  and 
inclined  to  be  horizontal.  The  ligamentum  teres  is  sometimes  thick- 
ened and  stretched,  owing  to  its  having  to  support  the  weight  of  the 
body.  In  some  cases  it  is  wanting  or  very  much  atrophied.  The 
acetabulum,  although  never  entirely  absent,  shows  a  want  of  devel- 
opment. It  may  be  oval  and  flattened,  or  it  may  be  small  and  shal- 
low, with  absence  of  its  cartilaginous  rim.  The  muscles  around 
the  hip  also  exhibit  a  lack  of  development.  As  a  result  of  this  dis- 
location the  pelvis  undergoes  certain  changes.  The  crests  of  the 
ilii  approach  each  other,  while  the  tuberosities  of  the  ischii  become 
farther  separated. 

Symptoms. — The  dislocation  is  seldom  recognized  until  the  child 
begins  to  walk,  when  a  peculiar  waddling  gait  is  the  first  symptom  to 
attract  attention,  and  it  is  noticed  at  the  same  time  that  the  back  is  very 
much  arched  (Fig.  62).  The  child  very  easily  becomes  fatigued,  but 
seldom  is  there  any  complaint  of  pain. 

By  Nelaton's  measurement  (from  the  anterior  superior  spine  of  the 
ilium  to  the  tuberosity  of  the  ischium)  a  displacement  of  the  trochanter 
upward  will  be  found  varying  from  half  an  inch  to  one  or  two  inches. 
By  gentle  traction  on  the  leg  the  trochanter  can  be  brought  down, 
and  measurement  will  show  that  the  leg  has  thus  been  lengthened, 


INJURIES  AND   DISEASES   OF  JOINTS. 


139 


but  as  soon  as  the  traction  is  discontinued  the  trochanter  will  be  found 
to   return  to  its  former  position. 

The  two  conditions  with  which  this  deformity  is  likely  to  be  con- 
fused are  bow-legs  and  infantile  paralysis.  The  resemblance  to  bow- 
legs is  marked  in  double  congenital  dislocation.  A  child  with  extreme 
bow-legs  has  a  waddling  gait  and  a  tilted  pelvis,  but  the  position  of  the 
trochanter  in  relation  to  Nelaton's  line  will  be  found  sufficient  to  settle 
the  question.  Infantile  paralysis  of  one  leg  may  bear  a  close  resem- 
blance   to    unilateral    dislocation,  while    the    laxity  of   the  joint  may 


Fig.  62. — Double  congenital   dislocation  of  hip  (from  a  photograph  in  the  collection  of  Dr. 

J.  E.   Moore). 


closely  simulate  luxation.  But  here,  again,  the  position  of  the  tro- 
chanter in  relation  to  Nelaton's  line  will  settle  the  diagnosis. 

Dislocation  at  the  Knee-joint. — Two  bones  may  be  dislocated 
at  the  knee-joint,  the  tibia  and  the  patella.  The  tibia  can  be  dislocated 
in  five  directions — forward,  backward,  outward,  inward,  and  rotary. 

Forward  dislocation  is  probably  the  most  common.  The  head  of 
the  tibia  can  be  felt  projecting  in  front  of  the  condyles  of  the  femur, 
w^hile  the  latter  bulge  backward  into  the  popliteal  space.  Numbness  is 
often  felt  as  a  result  of  the  stretching  of  the  nerves,  and  the  artery  and 
veins  may  be  seriously  injured  or  even  ruptured. 

Treatment. — Extension,  counter-extension,  and  direct  pressure. 


140  SURGICAL    DIAGNOSIS  AND    TKEATMENT. 

Backward  dislocation  is  generally  caused  by  direct  violence  in  the 
region  of  the  knee.  The  head  of  the  tibia  may  be  felt  bulging  back- 
ward into  the  popliteal  space,  while  in  front  there  is  a  corresponding 
depression  immediately  below  the  patella.  The  leg  is  in  a  position  of 
extreme  extension,  and  slopes  forward  so  as  to  form  an  obtuse  angle 
with  the  front  of  the  thigh.  The  dislocation  is  frequently  compound, 
and  the  most  serious  feature  of  it  is  the  injury  of  the  popliteal  vessels, 
which,  though  apparently  free  from  harm  at  the  time  of  the  accident 
may  have  their  coats  so  stretched  that  they  give  way  at  a  later  period, 
followed  by  gangrene  of  the  leg. 

Treatment. — Traction  and  direct  pressure. 

Lateral  luxations  are  rare  and  require  no  special  description. 

Rotary  Dislocations. — The  only  case  of  this  kind  seen  by  the 
writer  occurred  to  a  lumberman  whose  foot  was  held  firmly  in  a  deep 
track  in  the  frozen  snow  while  his  body  swung  round  upon  the  limb. 
The  displacement  was  recognized  and  reduced  by  his  fellow-workmen. 

Dislocations  of  the  Patella. — This  bone,  being  freely  movable, 
may  be  displaced  by  direct  violence,  by  muscular  action,  or  by  both 
forces  combined.  The  most  common  displacement  is  outward.  It 
sometimes  happens  that  the  bone  is  tilted  upon  its  edge  (vertical  dis- 
location), and  cases  are  recorded  in  which  the  bone  was  completely 
turned  front  backward.  The  patella  being  a  superficial  bone,  the  diag- 
nosis presents  no  difficulty.  The  dislocation  can  easily  be  reduced  by 
relaxing  the  quadriceps  and  placing  the  bone  in  position  by  direct 
pressure. 

Dislocations  of  the  Fibula. — The  upper  end  of  the  fibula  is 
rarely  dislocated.  The  most  common  displacement  is  outward  and 
forward.  It  can  occur  backward  and  also  upward.  The  displacements 
are  readily  recognized,  and  reduction  by  direct  pressure  is  easy.  At  the 
lower  end  of  the  fibula  the  few  dislocations  that  have  been  reported 
were  backward. 

Dislocation  of  the  Ankle. — Examination  of  the  ankle-joint 
after  injury  is  often  a  difficult  matter.  Swelling  is  likely  to  be  great, 
and  pain  so  intense  that  manipulations  cannot  be  borne  by  the  patient. 
The  injuries  that  must  be  taken  into  account  are  fractures  of  the  lower 
end  of  the  bones  of  the  leg,  fracture  of  the  astragalus,  dislocations  of 
the  foot  from  the  astragalus,  dislocation  of  the  astragalus  from  the 
tibia,  dislocation  of  the  astragalus  alone,  sprains  of  the  ankle,  and 
inflammatory  disease  in  the  joint. 

These  injuries  will  at  once  divide  themselves  into  two  great  classes, 
one  being  attended  with  deformity,  the  other  without  deformity. 

I.  Injuries  without  Apparent  Deformity. — Carefully  note  the  seat 
of  any  pain  or  tenderness.  Grasp  each  malleolus  separately  and  attempt 
to  move  it  independently  of  the  foot.  If  crepitus  can  be  felt  and  the 
malleolus  be  found  movable,  it  will  be  evidence  of  fracture  of  the 
malleolus.  If,  besides  fracture  of  the  lower  end  of  the  fibula,  there 
be  found  increased  lateral  mobility  of  the  ankle-joint,  you  may  decide 
that  the  internal  malleolus  is  broken  as  well,  or  that  there  is  laceration 
of  the  internal  lateral  ligament.     The  injury  is  Pott's  fracture. 

If  you  have  failed  to  find  any  fracture,  ask  the  patient  to  stand  upon 
the  injured  foot.     Should  this   cause   intense  pain,  you  may  suspect 


INJURIES  AND   DISEASES   OF  JOINTS.  141 

fracture  of  the  astragalus.  Move  the  foot  and  you  may  find  deep 
crepitus  ;  then  your  diagnosis  may  be  positive.  Should  the  results 
of  your  examination  be  negative,  make  careful  measurements  of  the 
length  of  the  leg,  the  distance  between  the  heel  and  the  malleoli,  also 
between  the  malleoli,  the  tubercles  of  the  scaphoid,  and  the  base  of 
the  fifth  metatarsal  bone.  Thus  you  can  detect  partial  displacement  of 
any  of  the  bones  which  might  not  be  apparent  to  the  eye. 

A  severe  pain  behind  either  malleolus,  with  swelling  and  tenderness, 
should  excite  suspicion.  Examine  carefully  for  the  tendons  which  pass 
behind  these  bony  prominences.  Possibly  there  is  a  depression  where 
the  tendon  ought  to  be,  or  the  tendon  may  be  felt  like  a  thick  cord  over 
the  side  of  the  malleolus.  If  on  the  inner  side,  these  symptoms  will 
indicate  dislocation  of  the  tendon  of  the  tibialis  posticus ;  on  the  outer 
side,  that  of  the  peroneus  longus. 

2.  Injuries  with  Deformity. — The  foot  is  displaced  outward  or 
inward.  If  outward,  it  is  evidence  of  one  of  three  injuries — viz. 
{a)  Pott's  fracture ;  \li)  Dupuytren's  fracture ;  (r)  Subastragaloid  dis- 
location. 

If  inward,  it  is  also  evidence  of  three  injuries — viz.  {a)  Dislocation 
of  the  ankle  inward ;  {U)  Subastragaloid  dislocation  inward ;  {c)  Dis- 
location inward  of  the  medio-tarsal  joint. 

Note  carefully  the  form  and  position  of  the  heel.  If  it  is  elongated 
or  unduly  prominent,  you  are  likely  to  find  one  of  the  following :  {a) 
Fracture  of  lower  end  of  tibia  ;  {t>)  Dislocation  of  ankle  backward ;  \c) 
Subastragaloid  dislocation  backward. 

If  the  heel  is  flattened,  it  may  be  the  result  of  one  of  three  injuries : 
(a)  Dislocation  of  the  foot  forward ;  {li)  Subastragaloid  dislocation  for- 
ward ;  (<r)  Fracture  of  the  os  calcis. 

Is  the  heel  raised  ?  It  indicates  one  of  three  things  :  {ci)  Fracture 
of  the  posterior  part  of  both  bones  of  the  leg  ;  {b)  Fracture  of  the  os 
calcis ;  (r)  Dislocation  of  the  foot  upward. 

After  completing  the  examination  and  finding  no  deformity,  no 
undue  mobility,  no  alteration  in  measurements  between  the  bony 
landmarks,  no  crepitus  or  displaced  tendons,  and  yet  the  joint  is 
painful,  hot,  and  swollen,  with  a  history  of  a  severe  twist  or  strain, 
the  only  diagnosis  to  be  made  is  a  sprain ;  the  tender  points  about  the 
joint  will  indicate  the  position  of  the  lacerated  ligaments. 

Dislocation  at  the  Ankle. — The  foot  may  be  dislocated  from 
the  tibia  and  fibula  in  any  of  four  directions — inward,  outward,  back- 
ward, or  forward.  A  very  rare  form  of  dislocation  has  been  met  with 
in  which  the  astragalus  has  been  driven  upward,  widely  separating  the 
tibia  from  the  fibula. 

Backward  Dislocation. — This  variety  is  the  result  of  extreme 
plantar  flexion  of  the  foot.  The  astragalus  slips  behind  the  tibia, 
causing  marked  lengthening  of  the  heel  and  corresponding  shortness 
of  the  foot  in  front.  One  or  both  malleoli  may  be  broken  in  this  or 
any  of  the  luxations  at  the  ankle.  Backward  dislocation  is  a  common 
accompaniment  of  Pott's  fracture. 

Forward  dislocation  is  the  result  of  forced  dorsal  flexion  (exten- 
sion), or  it  may  be  produced  by  a  blow  upon  the  heel.  The  symptoms 
are  just  the   opposite   to   those   found   in   the   preceding :  the  heel  is 


142  SURGICAL    DIAGNOSIS  AND    TRKA'JMENT. 

shorter,  the  foot  in  front  longer,  and  the  astragalus  can  be  felt  in  front 
of  the  tibia. 

Inward  dislocation  is  not  common.  Its  cause  is  extreme  inversion. 
It  is  generally  complicated  with  fracture  of  the  internal  malleolus  or 
the  lower  end  of  the  tibia,  rupture  of  the  external  lateral  ligament,  or 
fracture  of  the  external  malleolus. 

Outward  Dislocation. — This  is  simpl}'  a  complication  of  Pott's 
fracture. 

Subastragaloid  Dislocations. — An  astragalus  may  remain  artic- 
ulated with  the  tibia  and  fibula  while  the  other  bones  of  the  foot  are 
dislocated  from  it.  They  can  take  a  direction  backward,  forward,  out- 
ward, and  inward.  These  are  frequently  compound  dislocations,  and 
often  associated  with  other  serious  traumatisms.  When  simple,  the 
dislocation  is  usually  backward  and  to  one  or  the  other  side.  The  foot 
is  everted  or  inverted  and  in  the  position  of  plantar  flexion.  The  head 
of  the  astragalus  can  be  felt  as  a  rounded  tumor  on  the  dorsum  under 
the  skin ;  one  malleolus  stands  out  prominently,  while  the  other  is 
obscure. 

Treatment. — Draw  the  foot  forward  while  maintaining  it  in  extreme 
plantar  flexion  and  pressing  upon  the  heel.  Considerable  difficulty  has 
been  experienced  in  reducing  the  dislocation,  and  it  has  often  been 
found  necessary  to  divide  tendons  which  interfere  with  replacement. 

Dislocation  of  the  Astragalus. — In  this  variety  the  astragalus 
alone  is  displaced,  severing  its  connection  from  the  tibia  and  fibula  on 
the  one  hand,  and  from  the  bones  of  the  foot  on  the  other.  It  is,  as 
it  were,  squeezed  out  from  its  socket,  and  this  has  been  known  to  occur 
with  such  violence  that  the  bone  has  been  shot  through  the  skin. 

It  may  be  displaced  forward  or  backward,  but,  as  a  rule,  the  direc- 
tion is  a  complex  one,  such  as  forward  and  inward  or  outward  and 
forward. 

Dislocation  forward  is  a  result  of  over-distention.  The  bone  can 
be  readily  recognized,  either  partly  out  of  its  socket  or  completely 
displaced  forward,  and  resting  upon  the  cuboid  or  on  the  scaphoid  and 
cuneiform  bones.  Movement  is  totally  lost.  The  foot  is  turned  in  the 
direction  opposite  to  the  displacement — /.  e.  either  inward  or  outward. 

Dislocation  Backward. — The  astragalus  can  be  felt  behind  the 
ankle.     The  bone  is  frequently  fractured  as  well. 

Treatment. — The  incomplete  dislocation  forward  is  the  variety 
usually  met  with.  The  best  manipulation  consists  in  bending  the 
knee  and  making  traction  on  the  foot  while  in  the  position  of  plantar 
flexion.  The  bone  must  also  be  pushed  backward  by  direct  pressure. 
Sometimes  it  is  necessary  to  divide  the  tendo  Achillis  and  other  tissues 
that  happen  to  be  in  the  way.  Excision  of  the  bone  has  been  practised 
in  some  obstinate  cases.  Dislocations  of  the  remaining  tarsal  bones 
are  not  common.  The  most  frequent  is  probably  dislocation  of  the 
metatarsal  bones  from  the  tarsus — sometimes  all  together,  sometimes 
singly. 

Dislocations  at  the  metatarsal  and  phalangeal  articulations  of  the 
toes  are  so  similar  to  those  in  the  corresponding  joints  in  the  fingers 
that  they  do  not  require  a  separate  description. 

I/OOSe  Bodies  in  Joints. — A  person  while  walking  is  suddenly 


INJURIES  AND   DISEASES   OE  JOINTS.  1 43 

seized  with  a  sickening  pain  in  the  knee ;  the  limb  gives  way  beneath 
him,  and  he  suddenly  falls  to  the  ground ;  or  if,  during  any  ordinary 
movement  of  the  joint,  it  suddenly  becomes  locked  in  the  position  of 
flexion,  one  of  two  conditions  may  be  diagnosed :  (i)  A  loose  body 
in  the  joint;  (2)  A  displaced  semilunar  cartilage. 

I.  Loose  bodies  occur  only  in  the  large  joints,  and  out  of  every  10 
cases  9  are  found  in  the  knee.  These  bodies  are  sometimes  called 
"  loose  cartilage,"  from  the  fact  that  their  structure  resembles  that 
tissue.  They  are,  however,  often  fibrous  and  sometimes  bony.  In 
size  they  vary  from  a  small  pea  to  the  size  of  the  patella.  One,  two, 
three,  or  more  may  be  found  in  one  joint,  either  free  in  the  cavity  or 
attached  by  a  pedicle  to  the  synovial  membrane.  Their  most  common 
origin  is  from  villous  outgrowths  of  the  articular  cartilage  or  the  syno- 
vial membrane.  Rarer  sources  are  osteophytes,  blood-clots,  and 
neoplasms. 

Symptoms. — In  many  cases  there  is  more  or  less  effusion  of  synovial 
fluid,  giving  the  characters  of  a  chronic  synovitis,  and  causing  more  or 
less  discomfort  from  distention  of  the  joint.  It  is  when  the  so-called 
"  loose  cartilage  "  slips  between  the  bones  and  the  weight  of  the  patient 
comes  down  upon  it  that  the  characteristic  symptoms  appear.  Few 
conditions  can  compare  with  the  horrible  sickening  pain  then  felt  by 
the  unfortunate  patient.  He  falls  almost  fainting  to  the  ground.  The 
articular  cartilages  are  crushed,  the  ligaments  are  overstretched,  and 
the  bones  are  forced  apart  by  the  intruder.  It  may  happen  that  the 
joint  becomes  locked,  and  cannot  be  moved  until  the  body  is  dis- 
lodged by  manipulation  or  slips  out  unaided.  The  irritation  set  up  in 
the  joint  is  soon  followed  by  an  acute  synovitis,  which  fills  the  cavity 
with  fluid.  If,  after  such  an  occurrence  as  this,  you  examine  the  knee, 
you  will  find  evidence  of  the  body.  It  is  most  likely  to  be  found  just 
below  the  condyle  at  the  outer  side  of  the  joint.  Several  examinations 
may  be  necessary  before  it  is  definitely  located,  and  even  then  it  slips 
away  as  soon  as  it  is  touched.  Patients  soon  get  into  the  way  of  find- 
ing the  bodies  for  themselves,  and  often  become  expert  in  dislodging 
them  from  a  mischievous  position  to  one  in  which  they  give  no  trouble. 
Left  to  themselves,  however,  these  cases  are  liable  to  grow  serious. 
Repeated  attacks  of  synovitis  lead  to  degeneration  of  the  membrane, 
causing  thickening  and  the  formation  of  fringes.  The  synovitis  passes 
from  the  acute  to  the  chronic  condition,  and  the  joint  is  permanently 
impaired. 

Treatment. — If  seen  soon  after  the  body  has  slipped  between  the 
bones,  the  joint  may  be  found  locked,  and  the  first  point  is  then  to 
dislodge  the  body.  This  is  done  by  alternately  flexing  and  extending 
the  limb  (if  necessary,  under  an  anesthetic),  after  which  the  joint  is 
immobilized  and  the  synovitis  treated  until  all  irritation  shall  have  sub- 
sided. Formerly  various  means  were  resorted  to  for  the  purpose  of 
fixing  the  movable  body  in  some  harmless  position  without  opening 
the  joint,  but  with  the  safeguards  we  now  possess  in  aseptic  operations 
the  only  treatment  worth  entertaining  is  complete  removal  of  the  body 
by  an  incision.  After  fixing  the  body  with  the  fingers  or  by  thrusting 
a  needle  through  it,  an  incision  is  made  into  the  joint  and  the  body 
pressed  out  or  grasped  by  forceps  and  withdrawn.     The  wound  should 


144  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

be  closed  with  two  layers  of  catgut  sutures,  one  to  secure  the  synovial 
membrane,  the  other  to  close  the  opening  in  the  skin.  A  careful  asep- 
tic dressing,  followed  by  a  plaster-of- Paris  cast  or  splint,  completes  the 
operation. 

2.  Displacement  of  a  Semilunar  Cartilage. — This  is  an  accident 
very  similar  to  the  preceding,  and  the  symptoms  are  almost  identical. 
The  older  authors  were  in  the  habit  of  speaking  of  it  under  the  vague 
term  "  internal  derangement  of  the  knee-joint."  When  the  cartilage 
becomes  displaced  and  slips  between  the  bones,  the  same  symptoms  are 
produced  as  in  the  case  of  loose  bodies  in  the  joint.  It  usually  occurs 
in  connection  with  chronic  synovitis  or  osteo-arthritis — diseases  which 
have  a  tendency  to  impair  the  vitality  of  the  cartilages  and  dispose 
them  to  become  easily  detached.  The  cartilage  is  not  so  easily  felt  as 
is  a  loose  body,  but  the  internal  semilunar  is  the  one  most  commonly 
affected. 

Treatment. — The  cartilage  is  replaced  when  it  causes  locking  of  the 
joint  by  flexion,  extension,  and  rotation,  under  anesthesia  if  necessary. 
The  joint  should  then  be  immobilized  until  all  inflammator)-  action 
subsides,  after  which  an  elastic  knee-cap  may  prove  very  useful.  When 
the  cartilage  cannot  be  replaced,  and  when  it  gives  persistent  trouble, 
incision  of  the  joint  is  advisable.  Two  courses  are  then  open  to  the 
surgeon,  one  being  to  replace  the  cartilage  and  stitch  it  to  the  perios- 
teum, the    other  to  remove  it  entirely. 

II.   DISEASES  OF  JOINTS. 

As  a  rule,  there  is  no  difficulty  in  distinguishing  between  injuries 
and  diseases  of  joints.  Injuries  of  joints  are  associated  with  trau- 
matism, and  it  only  remains  for  us  to  diagnose  between  the  different 
lesions  that  could  possibly  be  produced  by  a  given  combination  of 
forces.  Diseases  of  joints  are  more  tardy  in  their  development,  and,  as 
a  rule,  have  no  immediate  connection  with  violence. 

In  the  examination  of  a  joint  for  disease  the  first  point  to  be  deter- 
mined is  whether  there  is  organic  disea.se  of  the  part,  and  thus  exclude 
hysteria,  which  is  so  common  a  disturbing  element  in  our  estimate  of 
joint-affection.  Here  the  history  will  afford  valuable  aid  by  showing 
evidence  of  other  developments  of  hysteria  or  strong  emotional  dis- 
turbance. If  the  patient  complains  of  violent  pain  in  a  joint  in  which 
there  is  no  swelling,  no  redness,  no  wasting  of  muscles,  and  a  marked 
hyperesthesia  of  the  skin,  out  of  all  proportion  to  the  other  conditions, 
a  close  scrutiny  for  hysteria  is  decidedly  in  order.  Notice  the  position  in 
which  the  joint  is  held.  It  may  exactly  simulate  one  of  the  characteristic 
positions  of  disease,  but  a  little  further  inquiry  may  reveal  the  fact  that 
other  positions  are  assumed  at  times.  The  pain  caused  by  passive 
motion  may  appear  to  be  unbearable,  but  if  the  patient's  attention  be 
directed  to  something  else,  the  same  movements  can  be  made  without 
difficulty.  Anesthesia  is  an  infallible  aid  in  cases  of  grave  doubt. 
While  under  an  anesthetic  the  hysterical  joint  can  be  freely  moved, 
and  rigidity  of  the  muscles  returns  only  with  consciousness,  but  in 
organic  disease  rigidity  reappears  just  as  soon  as  deep  anesthesia 
passes  off. 


INJURIES  AND   DISEASES    OF  JOINTS.  1 45 

Having  excluded  hysterical  joints,  the  consideration  of  organic 
disease  will  be  considered  under  the  following  heads  :  synovitis,  arthri- 
its,  and  osteo-arthritis. 

Examination  of  Joints  for  Disease. — Having  taken  a  full 
history  of  the  case  as  described,  you  should  proceed  to  make  a  sys- 
tematic examination  of  the  joint,  gaining  at  the  outset  the  confidence 
of  your  patient,  and  leaving  until  the  last  anything  likely  to  produce 
pain.  Not  only  the  joint,  but  the  whole  limb,  should  be  stripped  of  all 
clothing,  and  the  opposite  member  should  be  similarly  dealt  with  for 
purposes  of  comparison. 

Inspection. — For  the  shoulders,  elbows,  knees,  or  ankles  the  patient 
may  be  seated  in  good  light ;  for  the  hip,  it  is  necessary  that  he  should 
lie  at  full  length  upon  a  firm  table.  The  skin  should  first  be  noted  as 
to  its  color  and  the  presence  of  scars,  sinuses,  or  other  markings.  Is 
the  part  enlarged  or  wasted  or  deformed,  or  flexed  or  distended  or 
otherwise  displaced  ? 

Measurement. — Measurement  is  specially  valuable  in  examination  of 
the  hip  to  show  shortening,  which  is  proof  of  the  destructive  period  of 
hip-joint  disease.  It  is  also  important  to  measure  the  circumference 
of  the  parts  to  demonstrate  the  degree  of  wasting. 

Palpation. — Tenderness  is  a  very  important  sign,  and  pressure  should 
be  employed  with  gentleness.  Swelling  about  a  joint  is  elastic  and 
fluctuating  when  the  synovial  membrane  is  inflamed  and  its  sac  filled 
with  fluid.  The  ends  of  the  bone  may  be  felt  enlarged  and  swollen 
from  commencing  ostitis. 

Passive  Motion. — With  great  gentleness  the  limb  above  and  below 
the  affected  joint  should  be  grasped  and  the  range  of  motion  ascer- 
tained. The  presence  of  grating  may  be  noticed  when  the  bones  are 
moved  against  each  other.  If  necessary,  this  part  of  the  examination 
should  be  conducted  under  anesthesia. 

Exploration. — In  the  case  of  suppurating  sinuses  the  probe  is  used 
to  locate  the  position  of  diseased  bone. 

The  most  common  disease  of  joints  is  inflammation.  We  apply 
various  names  according  to  the  structure — e.  g.  Synovitis,  inflammation 
of  the  synovial  membrane  ;  Thecitis,  inflammation  of  the  sheaths  of  the 
tendons ;  Syndcsoniitis,  inflammation  of  the  ligaments ;  Arthritis,  or 
osteo-arthritis  or  pan-arthritis  when  all  the  structures  of  the  joint  are 
involved. 

Simple  Acute  Synovitis. — This  is  the  simplest  of  the  inflam- 
matory diseases  of  joints.  It  is  seldom  that  the  synovial  membrane  is 
alone  affected,  for  the  disease  is  likely  to  involve  the  other  structures, 
although  to  a  less  degree. 

The  causes  of  synovitis  are  local  and  constitutional.  Of  the  local 
causes  we  may  name  injury,  such  as  wounds  or  sprains,  extension  of 
the  disease  from  bone  or  other  neighboring  tissues,  and  exposure  to 
cold.  Of  constitutional  causes  rheumatism,  syphilis,  and  gout  are  the 
most    important. 

Symptoms. — Pain  is  a  prominent  symptom.  It  is  usually  severe,  of 
a  throbbing  character,  worse  at  night,  and  greatly  aggravated  by  pres- 
sure or  any  attempt  at  movement.  Heat  is  nearly  always  present,  and 
compared  with  the  sound  joint  there  may  be  a  difference  of  one  or 
10 


146  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

even  two  degrees.     Redness  is  not    seen  except  in  advanced  inflam- 
mation. 

Tlie  position  of  the  limb  is  characteristic.  The  patient  instinctively 
places  it  in  the  position  of  greatest  ease,  and  keeps  it  there.  The 
joint  is  usually  flexed.  The  part  is  swollen,  and  the  synovial  sac  dis- 
tended with  fluid.  In  the  knee  the  patella  will  be  found  floating,  as  it 
were,  on  the  effusion,  so  that  it  is  only  when  pressed  upon  that  it  comes 
in  contact  with  the  other  bones.  The  depressions  which  normally 
exist  on  either  side  of  it  and  down  along  the  ligamentum  patellar  are 
filled  out  and  rounded  by  the  fluid.  \\y  placing  a  hand  upon  either 
side  of  the  patella  fluctuation  can  be  readily  detected.  If  the  joint  is 
but  moderately  distended,  make  pressure  above  the  patella,  and  you 
will  find  that  the  fluid  is  driven  down  to  the  lower  part  of  the  cavity, 
causing  it  to  bulge  outward  and  pressing  the  patella  farther  forward. 

In  the  hip  the  fulness  is  most  marked  beneath  Poupart's  ligament 
and  behind  the  great  trochanter,  especially  when  the  limb  is  flexed  and 
abducted,  and  in  thin  subjects  fluctuation  can  be  felt  from  one  to  the 
other  of  these  positions.  Another  point  at  which  fluctuation  or  tume- 
faction can  be  detected  is  in  the  angle  between  the  thigh  and  the 
perineum,  a  little  behind  the  tendon  of  the  adductor  longus  muscle. 
Pain  is  severe  and  runs  down  the  thigh  ;  in  some  cases  it  is  referred 
entirely  to  the  knee. 

In  the  shoulder  the  fluid  causes  the  deltoid  to  bulge  outward.  The 
shoulder  looks  fuller  and  broader  than  its  fellow,  and,  especially  at  the 
upper  end,  there  is  a  loss  of  the  groove  which  separates  this  part  from 
the  chest.  These  changes  in  contour  are  best  observed  by  looking 
down  upon  the  joint  while  the  patient  is  seated  in  a  low  chair.  The 
seat  of  the  greatest  tenderness  is  in  front,  just  belpw  the  acromion 
process. 

In  the  ankle  look  for  this  fulness  behind  the  malleoli  on  either  side 
of  the  tendo  Achillis,  and  in  front  where  it  pushes  forward  the  exten- 
sor tendons.  In  the  elbow  it  fills  up  the  space  on  either  side  of  the 
triceps.  Another  point  of  bulging  is  where  the  radius  joins  the 
humerus,  and  this  is  also  the  most  painful  spot.  Fluctuation  can  be 
felt  between  this  point  and  those  just  mentioned.  When  the  bulging  is 
marked  the  triceps  tendon  appears  like  a  broad  depression. 

At  the  wrist  the  tumefaction  is  at  the  back  of  the  joint  on  each  side 
of  the  extensor  tendons  of  the  fingers  and  between  those  of  the  thumb. 
This  swelling  must  be  distinguished  from  dropsy  of  the  '  tendinous 
sheaths,  which  is  longitudinal,  while  that  of  synovitis  is  transverse, 
resembling  a  bracelet. 

It  is  not  common  to  find  a  simple,  serous  synovitis  pass  into  a  sup- 
purative condition,  except  when  by  careless  aspiration  or  some  other 
means  septic  germs  find  an  entrance  from  without,  thus  infecting  the 
aseptic  fluid  in  the  joint.  We  should,  however,  be  on  the  watch  for 
evidence  of  suppuration,  the  signs  of  which  are  persistent  or  increased 
pyrexia,  rigors,  rapid  increase  in  the  swelling,  and  general  depression 
of  the  vital  powers.  The  swelling  assumes  a  doughy  character,  and  in 
the  worst  cases  the  skin  pits  on  pressure.  In  three  or  four  days  the 
muscles  begin  to  contract,  causing  a  flexion  of  the  joint  and  malposition 
of  the  limb. 


INJURIES  AND  DISEASES   OF  JOINTS.  1 47 

Trcatnicnt. — Place  the  joint  at  perfect  rest.  In  the  early  stages 
cold  applications  by  means  of  ice-bags  or  constant  irrigation  will  check 
the  progress  of  the  disease  and  relieve  pain.  Later,  heat  will  afford 
more  relief  Hot  fomentations  of  lead  and  opium  are  very  soothing 
and  have  long  enjoyed  a  good  reputation.  Over  this  a  thick  layer  of 
absorbent  cotton  should  be  applied  and  compression  made  by  a  flannel 
or  rubber  bandage.  Should  the  fluid  continue  to  increase  in  spite  of 
all  treatment,  the  cavity  should  be  aspirated,  every  precaution  being 
taken  to  guard  against  sepsis.  As  soon  as  the  inflammation  has  sub- 
sided passive  motion  should  be  commenced,  and  gentle  movement 
practised  each  day  to  prevent   adhesions. 

Dry  Synovitis. — Dry  synovitis  or  croupous  synovitis  is  a  variety 
in  which  there  is  a  lack  of  serous  fluid  or  marked  swelling.  The 
synovial  membrane  has  a  hard,  leathery  feeling,  produced  by  the 
coagulation  of  fibrin  in  and  about  the  joint-cavity.  The  fibrinous 
deposit  also  takes  place  in  the  periarticular  spaces  and  even  along  the 
sheaths  of  the  tendons.  The  disease  is  confined  almost  exclusively  to 
the  knee,  and  the  subjects  are  generally  rheumatic.  It  is  attended  with 
great  suffering,  and  has  a  tendency  to  end  in  ankylosis ;  and  so  rapid 
is  the  process  that  a  joint  has  been  known  to  become  truly  ankylosed  in 
three  weeks.  Another  termination  is  suppuration,  which  is  as  extensive 
as  the  fibrinous  deposit,  so  that  not  only  the  joint  itself,  but  the  sheaths 
of  the  tendons  for  some  distance,  may  be  involved.  Fortunately,  this 
termination  is  rare. 

Syinpiouis. — The  most  marked  s}'mptom  of  dry  synovitis  is  pain. 
At  the  onset  it  is  not  very  severe,  but  after  the  lapse  of  several  days  it 
becomes  intense.  Naturally,  with  increase  in  the  severity  of  the  pain 
and  other  symptoms  indicating  synovitis,  the  surgeon  looks  for  swelling 
of  the  joint  and  the  characteristic  bulging  spoken  of  under  the  diagnosis 
of  Sero-synovatis.  This  swelling,  however,  is  wanting,  and  instead 
there  is  a  hard,  elastic,  and  leathery  sensation  communicated  to  the 
finger  when  the  joint  is  palpated.  The  muscles  in  the  neighborhood 
of  the  articulation  rapidly  atrophy,  thus  giving  the  joint  the  appearance 
of  enlargement,  which  on  measurement  it  will  be  found  not  to  possess. 
The  joint  has  a  peculiar  angular  or  square  look  ;  when  the  finger  is 
passed  down  the  limb  from  the  healthy  to  the  diseased  parts  an  abrupt 
rounded  edge  marks  the  limit  of  the  fibrinous  deposit. 

Treatment. — The  intensity  of  pain  demands  a  liberal  use  of  sedatives 
both  general  and  local.  Hypodermic  injections  of  morphin  are  usually 
indispensable.  The  action  of  the  skin  and  the  kidneys  should  be  main- 
tained by  diaphoretics  and  diuretics.  For  local  treatment  hot  applica- 
tions combined  with  laudanum  or  belladonna  are  soothing,  and  after  the 
first  few  days  may  displace  the  morphin  injections.  As  soon  as  the 
acute  symptoms  have  passed  off  the  splint  should  be  removed,  and 
passive  motion  gently  employed  to  prevent  ankylosis. 

Chronic  Synovitis. — Chronic  synovitis,  in  a  large  proportion  of 
cases,  is  the  sequel  of  an  acute  attack.  This  is  liable  to  be  the  case 
when  there  has  been  want  of  care  in  keeping  the  joint  at  rest  or  when 
any  cause  of  irritation  has  been  allowed  to  continue.  Sometimes  the 
character  of  the  synovitis  is  chronic  from  the  first.  In  this  case  it  is 
rare   to   have  the  inflammation    confined  to   the  synovial   membrane. 


148  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

INIaiiy  cases  of  osteo-arthritis  bc^in  as  a  synovitis.  This  is  particularly 
the  case  with  adults,  while  in  children  joint-disease  has  its  startini^-point, 
as  a  rule,  in  an  ostitis. 

Syniptoiiis. — Instead  of  the  acute  throbbing  pain  which  is  so  marked 
a  character  of  acute  synovitis,  we  find  here  an  almost  painless  affection. 
The  local  temperature  is  slightly,  if  at  all,  raised  above  the  normal,  and 
there  is  but  little  constitutional  disturbance.  Still,  there  is  the  disten- 
tion of  the  sNMiovial  sac  which  denotes  effusion.  The  shape  of  the  joint 
is  different  from  what  is  found  in  the  acute  form.  Instead  of  the  pouches 
on  each  side  of  the  patella  being  distended,  the  greatest  bulging  will  be 
found  beneath  the  quadriceps.  The  joint  is  weak,  and  gives  the  patient 
a  feeling  of  insecurity.  A  very  characteristic  sign  is  a  crackling  or 
grating  sound,  produced  by  the  fringes  of  the  thickened  membranes  as 
they  are  pressed  upon  by  movements  of  the  joint.  Flexion  is  usually 
permissible,  but  extension  is  greatly  impaired.  The  bones  appear  to 
stick  out  with  undue  prominence,  but  this  is  in  the  main  due  to  the 
wasted  condition  of  the  muscles. 

Trcatmoit. — Effusion  of  fluid  in  a  joint  is,  like  dropsy  or  jaundice, 
a  symptom  rather  than  a  disease.  Treatment  must  therefore  be  directed, 
in  a  great  measure,  to  the  condition  upon  which  the  synovitis  depends, 
such  as  tuberculosis  or  arthritis.  In  cases  of  no  great  duration  rest  and 
pressure  may  be  sufficient.  The  best  immobilization  is  obtained  by  the 
use  of  a  plaster-of-Paris  bandage.  Massage  often  proves  invaluable 
here,  and  baths,  friction,  electricity,  and  iodin  have  their  advocates. 
Many  of  the  cases  show  a  disposition  to  recurrence.  The  fluid  may 
be  nearly  absorbed  when  the  slightest  disturbing  cause  starts  it  up,  and 
soon  the  joint  is  distended  to  its  full  capacity.  For  this  it  has  been 
recommended  to  aspirate  the  joint  and  inject  it  with  some  irritating 
fluid,  such  as  carbolic  acid  or  a  weak  solution  of  iodin.  The  reaction 
is  often  severe,  and  must  be  taken  into  account.  In  tubercular  cases 
iniections  of  iodoform  emulsions  often  prove  very  satisfactoiy.  These 
will  be  spoken  of  in  the  treatment  of  Tubercular  Arthritis. 

Arthritis. — This  signifies  inflammation  of  all  the  tissues  of  the 
joint.  It  is  sometimes  spoken  of  as  osteo-arthritis  when  the  bony 
structure  plays  a  prominent  part,  or  pan-arthritis  when  destructive 
changes  are  apparent  in  all  the  articular  tissues.  The  causes  may  be 
summed  up  under  the  following  heads  :  {a)  Traumatism ;  {b)  Pyogenic 
organisms  ;  (r)  Tuberculosis  ;  id)  The  organisms  of  acute  infections, 
as  typhoid  fever;  (r)  Gonorrhea;  (/)  Rheumatism;  {g)  Gout;  {Ji) 
Syphilis. 

Simple  acute  arthritis  resembles  in  many  respects  acute  synovitis. 
The  difference  is  that  here  we  have  all  parts  of  the  joint  participating 
in  the  inflammatory  process,  and  the  symptoms,  as  a  rule,  are  more 
marked.  Pain  is  more  intense  ;  the  whole  joint  is  swollen,  and  not  the 
synovial  sac  alone.  Instead  of  a  fluctuating  swelling,  there  is  a  more 
uniform  roundness  and  a  feeling  of  more  density  and  resistance  than 
when  the  synovial  membrane  alone  is  inflamed.  If  the  disease  pro- 
gresses, destructive  changes  begin  to  manifest  themselves ;  the  liga- 
ments lose  their  tone,  soften,  and  give  way,  causing  undue  mobility 
of  the  joint.  This  may  even  be  followed  by  changes  in  the  relation 
of  the  bones  to  one  another,  amounting  perhaps  to  complete  disloca- 


INJURIES  AND   DISEASES   OF  JOINTS.  1 49 

tion.  The  cartilages  lose  their  smoothness,  and  friction  is  felt  when  the 
articular  surfaces  are  moved  upon  each  other.  During  sleep  the  invol- 
untary action  of  the  muscles  brings  these  eroded  articular  surfaces 
forcibly  together,  producing  those  "  starting  pains "  which  form  so 
painful  an  accompaniment  of  this  affection.  Perhaps  it  would  be 
more  correct  to  say  that  these  pains  occur  just  before  going  to  sleep. 
It  is  when  the  patient  is  losing  consciousness  and  the  wearied  muscles 
have  ceased  their  vigilance  that  a  friction  of  eroded  or  granulating 
cartilages  sets  up  a  slight  irritation.  Very  slight  it  may  be,  yet  suf- 
ficient to  produce  a  reflex  act  which  throws  the  muscles  into  violent 
contraction  and  bring-s  together  with  cruel  force  those  surfaces  which 
are  so  exquisitely  sensitive. 

From  the  joint  proper  the  inflammatory  process  is  likely  to  spread 
to  the  surrounding  structures.  The  muscles  atrophy  more  and  more, 
edema  and  swelling  increase,  the  skin  becomes  red,  hectic  symptoms 
supervene,  the  joint  is  becoming  septic,  and  suppuration  is  soon  fully 
established. 

It  may  be  difficult  to  decide  whether  the  joint  proper  is  the  seat  of 
the  disease  or  the  surrounding  tissues. 

The  following  points  of  difference  should  be  sufficient  to  settle  the 
question : 

Acute  Arthritis.  Inflammation  External  to  the  Joint. 

The  constitutional  symptoms  are  marked.  No  constitutional  symptoms,  or  they  may  be 

slight. 

Inspection  of  Joint. 
The  swelling  is  bilateral.  The  swelling  is  unilateral. 

Palpation. 
Fluctuation  is  often  found  over  the  synovial     Fluctuation  felt  at  the  seat  of  the  swelling, 
pouches.  wherever  it  may  be. 

Motion. 
Impaired,  owing  to  destruction  of  joint  in     Motion    only    impaired   by   swelling   of    the 
late  stages.  parts. 

Disorganization  of  the  Joint. 
Disorganization  often  complete.  No  disorganization. 

Tertnination. 
Destruction  of   the    joint  or   long-continued     Discharge  of  abscess  and  return  to  normal 
disease.  condition. 

Treatment  of  Acute  Arthritis. — The  directions  given  for  the  treat- 
ment of  synovitis  are  in  the  main  applicable  here.  Rest  is  of  the  first 
importance,  and  is  best  secured  by  the  use  of  a  suitable  splint.  In  the 
case  of  the  hip  and  the  knee  extension  not  only  secures  rest,  but  pre- 
vents muscular  spasm,  and  is  the  best  means  of  preventing  the  "  start- 
ing pains  "  already  referred  to.  It  prevents  the  rubbing  together  of 
the  articular  cartilages  and  serves  to  keep  the  limb  from  being  deformed. 
For  either  of  these  joints  Buck's  extension  is  a  convenient  arrange- 
ment. Cold  applied  to  the  joint  by  means  of  ice-bags  is  valuable  in 
the  early  stages,  and  compression  by  a  flannel  or  rubber  bandage  is 
useful. 


150  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

Constitutional  treatment  should  be  directed  to  any  diathesis  which 
may  be  present,  such  as  syphilis,  gout,  or  rheumatism.  When  pain  is 
severe  and  cannot  be  relieved  by  rest  or  local  applications,  hypodermics 
of  morphin  should  be  employed. 

The  treatment  of  many  of  these  cases  will  prove  long  and  tiresome. 
The  inflammation  may  subside,  fever  may  pass  away,  and  fluid  which 
has  been  effused  may  be  absorbed ;  but  a  chronic  condition  exists 
which  falls  far  short  of  the  normal  state  and  threatens  the  return  of  all 
the  acute  symptoms  on  the  slightest  provocation.  Under  these  circum- 
stances rest,  in  part  at  least,  must  be  maintained  by  allowing  the  patient 
to  go  about  on  crutches  with  a  plaster  cast,  or  in  case  of  the  hip  and 
knee  with  a  Thomas  splint.  The  main  object  of  this  line  of  treatment  is 
to  allow  the  patient  to  get  the  benefit  of  fresh  air  and  light  exercise, 
while  the  affected   joint  is  at  the  same  time  immobilized. 

Acute  Arthritis  with  Suppuration. — Suppurative  arthritis  may 
occur  primarily  or  may  invade  tlie  joint  from  the  surrounding  struc- 
tures. It  may  be  a  sequel  of  the  simple,  acute  variety  or  it  may  be 
septic  from  the  outset.  In  any  case  the  presence  of  the  organisms  of 
suppuration  is  essential.  Much  will  depend  upon  the  number  and 
virulence  of  the  germs  and  upon  the  vitality  and  resistance  of  the  tissues 
invaded.  Wounds  of  joints  made  by  a  non-sterilized  instrument  or 
wounds  that  have  not  been  aseptically  treated  form  a  large  class  of 
these  cases.  The  next  most  common  cause  is  an  ostitis  in  one  of  the 
bones  which  enters  into  the  formation  of  the  articulation.  At  the  knee 
the  starting-point  may  be  the  lower  end  of  the  femur  or  the  head  of  the 
tibia ;  at  the  hip,  the  head  of  the  femur.  If  the  surgeon  is  sufficiently 
careful,  he  can  long  foresee  this  serious  consequence  of  a  simple  ostitis. 
The  tenderness  on  pressure  over  one  particular  spot  in  the  bone,  with 
all  the  other  conditions  which  indicate  ostitis,  should  rouse  him  to 
action  long  before  the  disease  has  had  time  to  break  down  the  healthy 
barriers  which  lie  between  it  and  the  joint.  If  such  localized  disease 
in  the  bone  were  always  treated  promptly,  the  bone  opened  into,  and 
pus  got  rid  of  as  w-e  get  rid  of  it  in  any  other  locality,  a  vast  number  of 
cases  of  arthritis  would  be  prevented  and  an  incalculable  amount  of 
suffering  averted. 

Syviptouis. — The  symptoms  are  much  the  same  as  in  simple  acute 
arthritis,  but  more  severe.  Suppuration  is  recognized  by  a  rigor  or 
severe  chill,  which  may  be  oft  repeated.  The  temperature  rises  to  104°, 
105°,  or  even  106°.  The  joint  becomes  intensely  painful,  and  the 
swelling  not  only  causes  great  enlargement  of  the  joint,  but  spreads  up 
the  limb.  The  skin  is  red  or  dusky,  and  there  is  subcutaneous  edema 
more  or  less  extensive.  The  slightest  movement  aggravates  the  pain, 
and  the  muscles  are  kept  rigid_to  prevent  motion  in  the  joint.  When 
the  cartilages  have  become  eroded  the  ends  of  the  bone  grate  together, 
and  the  "  starting  pains  "  already  referred  to  become  intolerable.  Pus 
accumulates,  distends  the  joint,  and  gradually  makes  its  way  by  the 
route  of  least  resistance.  In  most  cases  this  is  through  the  skin,  but 
it  sometimes  happens  that  the  capsule  gives  way  at  its  weakest  point, 
allowing  the  pus  to  escape  along  the  muscle-tendons.  This  is  particu- 
larly the  case  with  the  knee,  the  capsule  giving  way  at  its  upper  portion, 
the  pus  burrowing  beneath  the  tendon  of  the  quadriceps  along  the 


IXJ CRIES  AND   DISEASES    OF  JOINTS.  151 

femur  to  form  a  new  abscess  higher  up  the  thigh,  which  if  not  properly- 
opened  and  drained  will  render  the  last  state  of  the  unfortunate  patient 
worse  than  the  first.  The  intensity  of  the  symptoms,  the  even  swelling, 
and  the  well-pronounced  chills  will  readily  distinguish  suppurative 
arthritis  from  synovitis.  If  there  is  still  doubt,  an  aspirator  can  be 
used  to  draw  off  some  of  the  fluid.  Should  this  prove  to  be  thin  and 
non-purulent,  the  case  is  one  of  synovitis.  Your  drawing  off  the  fluid, 
if  done  aseptically,  will  do  good  instead  of  harm.  Should  the  fluid  be 
purulent,  but  still  serous,  it  would  indicate  a  catarrhal  suppuration  of 
the  synov^ial  membrane,  and  aspiration  followed  by  a  mild  antiseptic 
washing  may  be  sufficient.  Should  the  contents  prove  to  be  thick  and 
curdy,  then  the  most  prompt  and  vigorous  measures  must  be  resorted 
to  in  order  to  save  the  joint. 

Trcatuicnt. — The  joint  should  be  laid  freely  open,  the  septic  con- 
tents washed  thoroughly  away,  and  the  most  thorough  drainage 
established.  In  the  case  of  the  knee  the  incisions  should  be  made  on 
each  side  of  the  patella.  In  addition  an  opening  should  be  made 
behind  the  joint.  The  safest  way  to  accomplish  this  is  to  pass  a  pair 
of  dressing-forceps  through  one  of  the  incisions  already  made  back- 
ward through  the  joint  to  the  popliteal  space,  a  little  to  the  outside  of 
the  middle  line.  When  the  end  of  the  instrument  can  be  felt  beneath 
the  skin,  cut  down  upon  it,  and,  driving  the  forceps  through,  grasp  a 
piece  of  rubber  tubing  and  carry  it  back  as  the  forceps  are  withdrawn. 
A  final  washing  out  may  be  effected  through  the  tubes,  first  of  sublimate 
solution,  I  to  2000,  and  lastly  of  sterilized  water.  After  this  the  joint 
is  put  up  in  a  moist  dressing  and  completely  immobilized  by  a  splint. 
A  rise  of  temperature  or  soaking  of  the  discharge  through  the  band- 
ages would  be  an  indication  for  a  renewal  of  the  dressings.  In  all 
cases  immobilization  should  be  as  complete  as  if  there  were  a  fracture. 
The  general  mode  of  recovery  is  by  bony  ankylosis,  but  early  and 
careful  treatment  may  result  in  a  perfect  joint. 

While  these  local  measures  are  receiving  attention  constitutional 
treatment  must  not  be  neglected.  The  patient  should  be  placed  in 
the  most  favorable  hygienic  conditions  and  given  nourishing  diet  and 
tonics. 

If,  in  spite  of  all  these  measures,  suppuration  continue,  further  ope- 
rative measures  must  be  resorted  to.  Of  these  the  most  conservative, 
and  often  the  most  satisfactory,  is  an  at\'pical  resection,  by  which  is 
meant  the  removal  of  only  the  structures  that  are  actually  diseased, 
leaving  the  parts  that  are  still  healthy.  Typical  resection,  which  im- 
plies total  excision  of  the  joint,  is  the  next  radical  procedure ;  and, 
lastly,  when  the  articulation  and  all  the  tissues  in  its  neighborhood 
are  hopelessly  destroyed  and  the  patient's  condition  critical,  amputation 
may  have  to  be  performed  as  the  only  means  of  saving  life. 

Pyemic  Arthritis. — One  of  the  most  disastrous  complications  of 
pyemia  is  multiple  arthritis.  Joint  after  joint  becomes  the  seat  of  sup- 
puration, and  its  destruction  is  often  rapid  and  complete.  It  always 
begins  in  the  synovial  membrane,  not  as  a  simple,  but  as  a  suppurating, 
synovitis.  The  symptoms  are  not  very  uniform.  In  some  cases  a  large 
number  of  joints  are  affected  in  rapid  succession  ;  in  others  there  maybe 
only   one  joint  invaded  or  there  may  be  long  intervals  between  the 


152  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

attacks.  The  joint  first  affected  is  generally  the  knee,  or  it  may  be  the 
right  sterno-clavicular  articulation.  Tain  may  be  slight  or  almost  want- 
ing. The  capsule  rapidly  fills  with  pus,  the  joint  becomes  swollen  and 
distended,  and  there  is  generally  a  rigor.  Otherwise  the  symptoms  are 
the  same  as  in  acute  suppurative  disease. 

Tubercular  Arthritis. — Of  all  causes  of  arthritis,  tuberculosis  is 
recognized  as  the  most  prevalent.  The  tubercle  bacilli  may  find  a 
lodgement  in  any  one  of  the  tissues  which  enter  into  the  formation  of 
the  joint,  but,  in  children  especially,  the  bone  is  the  structure  first 
invaded.  From  the  bone  the  route  to  the  joint-cavity  may  lie  through 
the  articular  cartilage,  or  by  a  more  roundabout  way  outside  the  car- 
tilage through  the  synovial  membrane  or  the  periarticular  structures. 

It  must  be  kept  clearly  in  mind  that  in  tubercular  joints  the 
morbid  process  is  not  suppurative,  but  the  growth  and  effects  of 
the  tubercle  bacilli.  The  joint  may  contain  fluid,  and  the  old  authors 
were  in  the  habit  of  speaking  of  these  collections  as  "  cold  or  chronic 
abscesses."  The  fluid  has  the  appearance  of  pus,  but  it  is  only 
when  the  joint  is  opened  and  the  pyogenic  organisms  are  per- 
mitted to  enter  that  true  suppuration  takes  place.  This  is  why  the 
opening  of  a  joint  before  the  days  of  antiseptic  surgery  was  looked 
upon  with  dread.  The  entrance  of  pus-germs  was  like  setting  fire  to 
the  prairie,  for  it  became  a  double  infection,  and  destructive  changes 
went  on  from  that  moment  with  frightful  rapidity.  In  children  the 
tubercular  process  begins,  as  a  rule,  in  the  bone.  In  adults  it  is  more 
liable  to  make  the  synovial  membrane  its  starting-point.  When  the 
membrane  is  affected,  either  primarily  or  secondarily,  it  becomes  cov- 
ered with  granulation  tissue,  which  spreads  to  the  other  structures. 
Soon  the  shape  of  the  joint  becomes  changed,  the  depressions  fill  out, 
and  there  is  a  soft  gelatinous  or  lardaceous  appearance  which  is  very 
characteristic.  The  parts  above  and  below  become  wasted,  while  the 
joint  itself  increases  in  size  and  assumes  a  spindle  shape.  The  skin  is 
white  and  often  traversed  by  distended  veins.  As  the  tubercular  de- 
posits break  down  and  liquefy  fluctuation  may  be  felt,  and,  unless  anti- 
septically  treated  and  got  rid  of,  this  fluid  will  sooner  or  later  find  its 
way  to  the  surface,  affording  a  portal  of  entrance  for  pyogenic  organ- 
isms, and  leaving  sinuses  which  may  continue  to  suppurate  indefinitely. 
Deformity  is  an  almost  constant  result  of  joint-tuberculosis.  It  begins 
by  the  patient's  assuming  the  position  of  least  discomfort,  a  position 
of  flexion.  It  is  aggravated  by  destructive  changes  in  the  ligaments, 
and  maintained  by  reflex  action  of  the  muscles. 

In  the  diagnosis  of  tubercular  arthritis  the  first  thing  to  exclude  is 
syphilis.  This  is  not  difficult,  for,  although  there  are  some  strong 
points  of  similarity  between  the  two,  syphilis  is  much  more  rare ;  there 
is  a  history  of  a  specific  sore,  and,  as  a  rule,  evidences  of  the  disease 
can  be  found  in  other  parts  of  the  body,  especially  in  the  glands,  and, 
should  there  still  be  a  doubt  of  the  disease,  put  the  patient  upon  a 
vigorous  antisyphilitic  treatment  for  two  weeks  and  note  the   result. 

Tubercular  disease  of  joints,  as  a  rule,  develops  very  slowly;  for 
many  weeks  or  even  months  there  may  be  only  a  disinclination  on  the 
part  of  the  patient  to  use  the  joint,  a  slight  limp,  a  stiffness  or  a  rigidity 
of  the  muscles.     Pain  may  be  slight  or  entirely  absent,  and  much  valu- 


INJURIES  AND   DISEASES   OF  JOINTS.  I  5  3 

able  information  may  be  gained  from  its  character.  When  the  disease 
begins  in  the  bone,  pain  is  usually  present  from  the  first,  and  the  affected 
spots  are  sensitive  to  pressure.  When,  on  the  other  hand,  the  synovial 
membrane  is  the  starting-point,  pain  is  usually  slight,  but  it  becomes  a 
prominent  symptom  when  the  disease  begins  to  involve  the  bone. 

In  the  early  stages  of  the  disease,  before  there  is  any  destruction  of 
tissue  or  liquefaction  of  tubercular  deposits,  the  diagnosis  may  be 
obscure.  A  safe  rule  to  follow  in  such  an  ev^ent  is  to  ^\\q  the  patient 
the  benefit  of  the  doubt  by  treating  him  for  tuberculosis.  In  the 
advanced  stage  there  is  little  likelihood  for  error.  Destructive  changes 
cause  shortening  of  the  limb,  and  may  even  produce  dislocation  of  the 
affected  joint.  These  points  can  be  best  brought  out  under  the  con- 
sideration of  tuberculosis  of  special  joints.  In  all  cases  evidence  of 
tuberculosis  should  be  sought  for  apart  from  the  suspected  joint,  as 
chronic  glandular  enlargement,  persistent  nasal  or  pulmonary  catarrh, 
and  a  family  history  of  the  disease. 

Tuberculosis  of  Special  Joints. — The  Hip-joint. — This  is  a 
disease  of  childhood,  but  by  no  means  confined  to  early  life.  Children 
between  the  ages  of  five  and  ten  years  make  up  a  majority  of  the 
cases.  The  starting-point  is  generally  the  under  surface  of  the  neck 
of  the  femur  at  the  articular  side  of  the  diaphysis.  There  may  be  two 
reasons  for  the  selection  of  this  spot :  one  that  it  is  most  subjected  to 
strains  and  concussions,  and  the  other  the  fact  that  the  vessels  enter  the 
bone  in  this  situation.  In  the  diagnosis  of  tubercular  disease  of  the 
hip  it  is  convenient  to  consider  three  stages  : 

First  Stage. — The  tubercle  bacillus  is  deposited  in  one  of  the  tissues 
of  the  joint — the  bones,  as  a  rule,  in  children,  the  synovial  membrane 
in  adults.  The  bacillus  multiplies  and  produces  new  growths  of  cheesy, 
gelatinous,  or  granulation  tissue.  In  this  stage  little  or  no  irritation 
may  be  produced,  and  the  symptoms  are  often  overlooked.  For  this 
very  reason  this  is  the  most  important  stage  of  the  disease  from  the 
points  of  diagnosis  and  prognosis.  Any  one  can  recognize  the  second 
or  third  stage,  but  the  man  who  properly  appreciates  the  symptoms  of 
this  incipient  stage  is  the  one  who  will  save  the  most  joints  and  effect  the 
greatest  number  of  cures.  Take  warning  from  the  following  danger- 
signals  :  The  child  becomes  easily  tired  and  shows  a  disinclination  to 
play.  There  is  a  slight  limp,  particularly  in  the  morning,  which  passes 
off  after  exercise.  The  mother  says  something  about  pains  at  the  thigh 
or  hip,  or  more  commonly  the  knee,  and  wonders  if  they  are  "  growing 
pains."  In  any  of  these  instances  the  joint  should  be  carefully 
examined.  Movement  may  be  perfect  and  pain  may  be  absent,  but 
about  the  hip  a  slight  rigidity  of  the  muscles,  especially  the  adductors, 
will  be  found  on  careful  palpation,  and  there  may  be  also  a  slight 
atrophy  of  the  muscles  of  the  thigh. 

Sixond  Stage. — This  is  the  stage  of  arthritis.  If  the  symptoms  were 
previously  obscure,  they  now  become  positive.  There  is  no  doubt  about 
a  limp,  for  it  gradually  advances  to  lameness.  The  child  is  easily 
fatigued ;  pain  is  worse  at  night  and  toward  the  early  morning  hours. 
Rigidity  of  the  adductors  and  atrophy  of  the  muscles  of  the  thigh  are 
now  unquestionably  present.  And  yet  up  to  this  time  attention  may 
be  directed  to  the  wrong  joint,  for  the  pain  may  be  persistently  felt  in 


154 


SURGICAL   DIAGNOSIS  AXD    TREATMENT. 


the  knee.  This  is  a  reflex  sensibiHty  due  to  the  anatomical  fact  that  the 
obturator  nerve  is  distributed  to  both  articulations.  Over  and  above 
these  symptoms  are  conditions  due  to  inflammatory  changes  in  the  joint. 
If  effusion  be  present,  there  will  be  distention,  most  apparent  under 
Poupart's  ligament  and  in  Scarpa's  triangle,  or  it 
may  appear  before  and  behind  the  great  trochanter, 
giving  the  hip  an  appearance  of  increased  width. 
Instinctively  the  patient  throws  the  weight  of  the 
body  on  the  sound  side,  causing  a  tilting  of  the  pel- 
vis, and  hence  the  affected  limb  is  advanced  and 
somewhat  abducted  and  everted.  The  older  surgeons 
spoke  of  this  as  apparent  lengthening  (Fig.  63).  Let 
the  patient  stand  up.  The  gluteal  fold  on  the  affected 
side  is  lessened  or  even  obliterated,  and  in  females 
the  line  between  the  vulvae  is  inclined.  In  rare  cases 
the  limb  will  be  found  to  be  adducted.  Pain  as  a 
symptom  must  not  be  too  implicitly  relied  upon. 
Along  the  obturator  nerve  is  the  most  likely  area  in 
which  to  find  it ;  that  is  to  say,  the  anterior  and 
lower  aspect  of  the  thigh  and  the  front  and  inner  sur- 
face of  the  knee.  Worse  at  night  it  is  almost  sure 
to  be,  and  in  advanced  periods  of  the  disease  the 
"  starting  pains  "  already  mentioned  are  likely  to  make 
their  appearance.  It  occasionally  happens  that  the 
disease  runs  its  course  with  a  very  slight  amount  of 
pain. 

Place  the  patient  at  full  length  upon  a  firm  table. 
Gently  grasp  the  knee  of  the  affected  side  and  press 
it  downward  so  as  to  bring  the  popliteal  space  in  con- 
tact with  the  table.  You  will  then  find  that  the  lumbar 
portion  of  the  spine  is  curved  upward  (Fig.  64).  Press 
the  spine  back  until  it  comes  in  contact  with  the  table  and  the  knee  is 
forced  to  bend  upward.     The  knee  and  the  lumbar  spine  act  recipro- 


FlG.  63. — Apparent 
lengthening        (after 

Say  re). 


FIG.  64.— Effects  on  the  lumbar  spine  of  flexing  and  extending  the  diseased  leg  in  hip-disease 

(Albert). 


cally.     This  is  due  to  contraction  of  the  psoas  iliacus  muscle,  and  is  a 
symptom  of  the  greatest  importance.     It  must  not,  however,  be  taken 


nVJURIES  AXD  DISEASES   OF  JOINTS. 


155 


as  a  pathognomonic  sign  of  morbus  coxs,  for  it  is  found  in  the  follow- 
ing conditions  as  well — viz.  bursitis  under  the  psoas  muscle,  psoas 
abscess,  and  sacro-iliac  disease  when  complicated  with  psoas  abscess. 

Effusion,  even  when  considerable  in  amount,  may  be  reabsorbed, 
but  it  is  just  as  likely  to  go  on  increasing  until  it  causes  the  weak- 
ened capsule  to  give  way.  The  fluid  pours  out  into  the  neighboring 
tissues,   infecting   them    with    myriads    of  tubercle   bacilli.      Tension, 


Fig.  65. — Intra-acetabular  luxation  in  coxalgia  (Tillmanns). 

which  has  been  gradually  increasing,  now  suddenly  ceases,  affording 
relief  to  suffering  and  an  apparent  improvement  in  the  patient's  condi- 
tion. This,  however,  is  of  short  duration.  The  fluid  continues  to 
burrow,  and  unless  properly  managed  will  eventually  find  an  outlet 
through  the  skin.  The  tubercle  bacilli  are  now  reinforced  by  pyogenic 
germs,  abscesses  and  sinuses  are  formed,  and  a  long  and  wasting 
period  of  suppuration  follows.  But  the  evil  effects  of  rupture  of  the 
capsule  and  escape  of  the  tubercular  fluid  do  not  stop  here.  With  the 
emptying  of  the  synovial  sac  the  articular  surfaces  of  the  bones  come 
closer  together ;  reflex  muscular  contraction  increases  their  friction  one 
upon  the  other ;  they  begin  to  break  dowm,  and  the  disease  enters  upon 
its  last  stage. 

TJiird  Stage. — This  is  the  period  of  dcstnidion.  The  acetabulum 
steadily  breaks  down  at  the  upper  segment  of  its  circumference,  the 
head  of  the  femur  following  up  the  erosion,  ploughing,  as  it  were,  a  fur- 
row along  the  dorsum  ilii,  changing  the  acetabulum  from  a  round  to  an 
oblong  depression  (Fig.  65).  This  is  often  spoken  of  as  a  pathological 
dislocation,  but  the  term  is  not  appropriate,  for  it  is  only  the  acetabulum 
that  is  changed ;  the  head  of  the  femur  does  not  leave  the  socket,  and 
the  capsule  forms  new  attachments  as  the  wasting  proceeds.  The  head 
and  neck  of  the  femur  also  suffer  in  the  destructive  process,  so  that 
shortening  soon  becomes  a  pronounced  symptom  in  this  third  stage  of 
the  disease.  Measurement  from  the  anterior  superior  spinous  process 
to  the  outer  or  inner  malleolus  will  show  a  shortening  of  a  half  inch, 


156 


SURGICAL   DIAGNOSIS  AXD    TREATMENT. 


Fig.  66. — Disease  of  hip,  showing  flexion 
and  adduction  (from  a  photograph  in  the  col- 
lection of  Dr.  T.  S.  Roberts). 


an  inch,  or  more.     Bryant's  and  Nclaton's  mea.surcments  will  demon- 
strate that  the  trochanter  is  higher  on  the  sound  side ;  hence  the  waste 

must  be  at  the  neck  of  the  bone 
or  in  the  acetabulum.  The  liga- 
ments may  be  destroyed  by  sup- 
puration or  they  may  lose  their 
hold  by  erosion  of  the  parts  of 
the  bones  which  afford  their  at- 
tachments. More  and  more  the 
thigh  becomes  flexed  (Fig.  66), 
and  adduction  may  take  the  place 
of  abduction. 

The  constitutional  .symptoms, 
which  have  been  more  or  less 
marked  in  the  previous  stages, 
now  assume  the  characters  of 
"  hectic  fever." 

From  this  point  the  disease 
may  turn  in  one  of  two  directions. 
In  favorable  cases  the  suppuration 
gradually  abates,  bone-destruction 
ceases,  and  repair  begins.  All  dead 
tissues  are  thrown  off  by  molec- 
ular wasting,  and  the  joint  is  left 
in  a  condition  of  bony  ankylosis. 
Unfavorable  cases  go  on  from 
bad  to  worse,  new  abscesses  and  sinuses  forming  until  exhausted 
nature  gives  way  and  death  brings  relief  More  frequently  it  happens, 
however,  that  the  tubercular  infection  spreads  to  some  of  the  internal 
organs,  generally  to  the  lungs,  and  the  journey  is  completed  by  a 
shorter  and  more  merciful  route. 

Treatment. — Bear  in  mind  that  the  tubercular  process  may  at  the 
outset  be  a  local  affection,  a  pure  culture  of  the  bacillus  in  a  rather 
unfavorable  medium  struggling  for  a  mastery  over  the  tissues  which  it 
has  invaded.  In  the  very  early  part  of  the  first  stage,  when  the  bacilli 
are  multiplying,  everything  which  gives  strength  to  the  normal  tissues 
will  retard  or  cut  short  the  deposit.  Good  hygienic  surroundings, 
nourishing  food,  perfect  digestion,  and  life  in  the  open  air  constitute 
the  main  safeguards.  When  possible,  a  change  to  the  air  of  the  sea- 
side, mountains,  or  pine  woods  should  be  made. 

Unfortunately,  we  do  not  often  see  a  case  in  this  early  stage,  and  if 
we  did  we  perhaps  should  fail  to  recognize  it.  The  bacilli  have  effected 
a  secure  lodgement  before  they  produce  the  irritation  which  gives  us 
even  the  early  symptoms.  To  allay  this  irritation  rest  of  the  affected 
part,  complete  and  absolute,  must  be  relied  upon  and  faithfully  em- 
ployed. It  is  beyond  question  that  early  immobilization  with  pro- 
longed rest  in  the  recumbent  posture  is  sufficient  to  check  the  disease 
in  a  majority  of  cases.  As  soon,  then,  as  the  diagnosis  is  made  the 
limb  should  be  put  up  in  a  Buck's  extension  appliance  and  the  patient 
kept  in  bed  until  inflammatory  symptoms  subside.  Almost  immediate 
relief  from  pain  will  follow  the  adoption   of  this   plan.     A  child,  no 


INJURIES  AND  DISEASES  OF  JOINTS. 


157 


matter  how  young  and  active,  soon  becomes  perfectly  reconciled  to 
the  restraint ;  pain  ceases  and  the  night-cries  and  starting  pains  are 
prevented.  When  it  is  possible,  however,  the  benefits  of  out-door  air 
and  exercise  should  be  secured,  while  at  the  same  time  the  joint  is  kept 
at  perfect  rest.  The  child  can  be  taken  out  on  a  cot  or  in  a  carriage, 
or,  if  the  acute  symptoms  are  well  under  control,  a  plaster-of-Paris  cast 
so  applied  as  to  control  the  limb  and  pelvis  will  answer  all  purposes. 
The  sole  of  the  shoe  on  the  sound  side  should  be  thickened  in  order 
to  take  all  weight  off  the  diseased  limb,  and  the  patient  should  move 
about  on  crutches.  Many  forms  of  traction  splints  have  been  devised 
having  for  their  object  the  immobilization  of  the  joint  and  prevention  of 
destruction  of  the  acetabulum  from  muscular  contraction.  The  splints 
in  most  favor  are  Thomas's  (Fig.  dj),  Phelps's  (Fig.  68),  Taylor's 
(Fig.  69),  and  Lovett's  (Fig.  70). 


Fig.  67. — Thomas's  pos-      FiG.  68. — Phelps's      FiG.  69. — Taylor's  splint.      FiG.  70. — Lovett's 
terior  splint.  splint.  splint. 

Operative  treatment  has  to  be  resorted  to  in  many  cases.  When 
the  joint  is  distended  with  fluid  it  may  be  aspirated  to  relieve  tension. 
If  the  accumulation  is  large  and  spontaneous  evacuation  is  threatened, 
an  incision  should  be  made  with  the  strictest  asepsis,  so  that  a  double 
infection  may  be  averted.  Injections  of  iodoform  have  proved  of  very 
great  value.  The  most  suitable  form  is  a  lo  per  cent,  emulsion  in 
glycerin,  care  being  taken  that  the  emulsion  is  itself  sterilized. 

Bruns  recommends  the  following : 


Iodoform, 
Glycerin, 
Distilled  water. 


10  parts ; 
50      " 
50      " 


The  first  injection  should  not  contain  more  than  half  a  dram  of  iodo- 
form, and  in  children  even  a  smaller  amount.     The  injection  should  be 


158 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


made  about  every  two  weeks.  In  fungous  joints  the  emulsion  should 
not  only  be  thrown  into  the  cavity,  but  also  into  the  thickened  capsule. 
When  tubercular  abscesses  exist,  they  should  first  be  evacuated,  and 
the  softened  tissue  scraped  out. 

When  the  disease  progresses  far  enough  to  cause  extensive  destruc- 
tion of  bone,  the  question  of  resection  may  have  to  be  considered. 
The  operation,  as  practised  of  late  years,  is  not  attended  with  serious 
danger,  but  it  must  be  admitted  that  the  results  are  often  disappointing. 
It  does  not  prevent  the  recurrence  of  the  disease  in  other  parts  of  the 
body,  and  it  may  happen  that  the  deformity  will  not  prove  much  less 


Fig.  71. — Sacro-iliac  disease  :  abduc- 
tion (Jones). 


Fig.  72. — Sacro-iliac  disease :  ad- 
duction (Jones). 


than  after  spontaneous  cure  with  ankylosis.  Yet  resection  is  advisable, 
as  it  shortens  the  period  of  suppuration  and  holds  out  the  best  prospect 
of  eradication  of  the  tubercular  deposits. 

The  incision  should  be  treated  by  the  open  method,  packed  with 
iodoform  gauze,  and  irrigated  with  corrosive-sublimate  solution 
(i  :  3000)  as  often  as  necessary.  The  joint  should  be  immobilized 
by  extension,  as  in  the  treatment  of  the  second  stage,  and  this  restraint 
persisted  in  for  six  or  eight  weeks  after  the  operation. 

The  Sacro-iliac  Joint. — A  very  serious,  but  fortunately  rare,  dis- 
ease is  tuberculosis  of  the  sacro-iliac  joint.  Adults  below  the  age  of 
thirty-five  form  the  majority  of  cases  met  with.     The  progress  of  the 


INJURIES  AND  DISEASES   OF  JOINTS.  I  59 

disease  is  slow  and  insidious,  and  has  to  be  carefully  diagnosed  from 
hip-disease,  rheumatism,  and  sciatica. 

Syuiptouis. — The  first  symptom  to  make  its  appearance  is,  according 
to  Robert  Jones  of  Liverpool,  a  peculiar  attitude,  a  "  listing  "  of  the 
trunk  toward  the  unaffected  side,  and  this  causes  the  spine  in  due  time 
to  assume  a  long,  sweeping  curve,  with  its  convexity  toward  the  sound 
side  (Figs.  71,  72).  Before  the  development  of  this  deformity  the  patient 
finds  that  he  easily  becomes  fatigued,  and  the  motions  of  bending  for- 
ward and  returning  to  the  perpendicular  are  difficult  for  him.  Tender- 
ness on  pressure  over  the  synchondrosis  is  generally  present,  and  con- 
tinued effort  in  standing  or  walking  produces  great  discomfort  and 
fatigue  ;  some  patients  complain  of  a  sensation  as  if  the  body  were 
falling  asunder.  Lying  upon  the  affected  side  increases  the  pain,  and 
it  is  generally  aggravated  while  the  patient  is  at  stool.  The  thigh  may 
become  flexed  as  in  hip-disease,  but  this  is  most  likely  to  be  the  case 
when  psoas  abscess  is  a  complication.  The  most  characteristic  sign  is 
the  pain  which  is  felt  when  the  ilia  are  pressed  together  by  grasping 
their  crests  and  moving  them  toward  or  apart  from  each  other.  Move- 
ment of  the  thigh  is  attended  with  severe  pain ;  but  if  the  pelvis  be 
steadied,  the  patient  lying  upon  his  back,  the  thigh  can  be  moved 
without  causing  suffering.  This  is  a  symptom  of  great  significance, 
and  is  a  valuable  diagnostic  point  between  hip-  and  sacro-iliac-disease. 
There  is  usually  tenderness  over  the  gluteal  region,  and  if  the  fingers 
be  passed  outward  toward  the  sacro-iliac  articulation,  a  spot  will  be 
found  which  is  excessively  tender  and  represents  the  seat  of  local 
changes.  The  first  change  in  the  contour  of  the  part  is  an  elongated 
swelling  near  the  affected  joint.  When  pus  collects  it  may  travel  in 
one  of  the  following  directions : 

1.  Through  the  anterior  ligament,  keeping  outside  the  pelvic  fascia — 
{a)  following  the  course  of  sacral  nerves  and  pyriformis,  out  through 
the  great  sacro-sciatic  foramen,  and  forming  an  abscess  under  the 
gluteus  maximus ;  {6)  following  the  curve  of  the  sacrum  behind  the 
rectum  to  a  point  in  the  ischio-rectal  fossa,  causing  inflammation  and 
adhesion  of  the  rectum,  and  ultimately  bursting  into  it ;  [c)  coursing 
under  the  lumbo-sacral  ligament  into  the  psoas  muscle,  and  thence 
into  the  thigh ;  {d)  or  into  the  iliacus  muscle,  and  thence  into  the 
groin. 

2.  Through  the  back  part  of  the  joint  into  the  multifidus  spinae, 
creeping  along  it  and  pointing  in  the  lumbar  region  (Fig.  j^,  or 
directly  over  the   joint  itself  (Jones). 

The  lameness  attending  sacro-iliac  disease  is  characteristic.  It 
comes  on  at  an  early  period ;  the  patient  leans  forward  and  favors 
the  limb  on  the  affected  side ;  he  walks  insecurely  and  realizes  a 
want  of  proper  support.  He  cannot  stand  on  the  affected  limb  or 
twist  himself  suddenly  around.  In  the  course  of  time  it  becomes 
impossible  for  him  to  stand  erect. 

The  limb  on  the  affected  side  seems  longer,  and  the  foot  may 
extend  half  an  inch  beyond  its  fellow,  but  measurement  from  the 
anterior  superior  spinous  process  to  the  external  malleolus  shows  that 
the  limbs  are  of  equal  length.  Nor  is  this  lengthening  due  to  tilting 
of  the  pelvis  as  in  coxalgia.     It  is  caused  by  a  tilting  forward  and 


i6o 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


rotation  downward  of  the  whole  side  of  the  pelvis,  due  to  inflamma- 
tory swelling  in  the  sacro-iliac  joint. 

The  diag)iosis  is  often  obscure,  and  must  rest  upon  tenderness  over 
the  joint,  pain  on  separation,  or  crowding  of  the  ilia  together,  and  upon 
the  painless  movement  at  the  hip  when  the  pelvis 
is  firmly  steadied. 

Sacro-iliac  disease  must  be  distinguished  from 
the  following :  llip-disease  is  lik'ely  to  simulate  it, 
particularly  when  the  symptoms  begin  in  the  ace- 
tabulum. The  early  signs  may  be  identical,  such 
as  fatigue,  pain  felt  at  the  knee,  etc.  The  diagnosis 
must  rest  upon  tenderness  on  pressure  and  puffiness 
over  the  sacro-iliac  joint,  which  arc  never  present  in 
hip-disease.  The  seat  of  pain  should  be  carefully 
noted.  In  sacro-iliac  disease  it  is  at  the  sacro-iliac 
junction  behind  and  away  from  the  hip.  Pressure 
made  deeply  in  the  hollow  behind  and  above  the 
great  trochanter  or  against  the  anterior  part  of  the 
hip-joint  gives  no  pain.  Movement  at  the  hip  is 
painful,  but  when  the  pelvis  is  steadied  these  move- 
ments are  free  from  pain. 

The  alteration  in  the  shape  of  the  limb  affords 
valuable  evidence.  In  advanced  stages  of  hip-disease 
there  is  marked  shortening,  never  in  sacro-iliac  dis- 
ease. 

(2)  Neuralgia  of  the  Hip. — This  is  common  in 
young  females,  and  is  often  complicated  with  hysteria. 
The  pain  extends  over  a  wide  area,  is  superficial  in 
character,  and  no  special  tenderness  can  be  found  at 
the  sacro-iliac  junction. 

(3)  Sciatica. — Every  obstinate  case  of  sciatica 
should  be  most  searchingly  examined  for  evidence  of  sacro-iliac  disease. 
The  subjects  of  sciatica  are  usually  more  advanced  in  years  than  those 
who  suflfer  from  the  joint  affection.  The  pain  is  below  the  joint;  the 
nerve  can  be  traced  down  the  thigh  by  its  sensitiveness  to  pressure,  and 
the  special  symptoms  of  sacro-iliac  disease  are  wanting.  In  sciatica 
pain   is  not  relieved  by  the   recumbent  position. 

(4)  Spinal  Disease. — If  too  much  stress  be  laid  upon  the  situation 
of  the  abscess,  sacro-iliac  disease  may  be  confounded  with  spinal  dis- 
ease. •  In  the  latter  there  is  usually  a  history  of  disease  in  the  vertebrae 
and  evidence  of  characteristic  change  in  the  curvature  of  the  spine. 

The  most  puzzling  cases  are  those  in  which  the  lumbo-sacral 
vertebrae  are  involved. 

(5)  Disease  of  the  Pelvic  Bones. — When  the  crest  of  the  ilium  or 
the  tuberosity  of  the  ischium  is  the  seat  of  localized  ostitis,  a  probe 
can  be  passed  down  to  the  diseased  bone,  and  then  there  is  no  change 
in  the  length  of  the  limb  or  the  size  of  the  pelvis.  The  greatest  dif- 
ficulty arises  when  the  acetabulum  is  the  seat  of  disease.  Pain  on 
movement  is  felt  in  this  case,  even  though  the  pelvis  be  steadied,  and 
the  limb  will  be  found  shortened  by  measurement  from  the  anterior 
superior  spine  to  the  external  malleolus.     Inflammation  of  the  sacro- 


^:::j 


Fig.    73.  —  Abscess 
in   sacro-iliac    disease 

(Jones). 


INJURIES  AND  DISEASES   OF  JOINTS. 


i6i 


iliac  joint  sometimes  occurs  in  gonorrheal  rheumatism  and  pyemia,  but 
in  those  cases  the  course  of  the  disease  is  rapid,  and  not  insidious  as  in 
tuberculosis. 

Treatment. — In  the  early  stages  rest  and  counter-irritation  are  indi- 
cated. An  apparatus  such  as  that  shown  in  Fig.  74  may  be  employed. 
When  there  is  pus,  free  openings  and  drainage  must  be  secured. 
Injections  of  iodoform  emulsion  should  have  a  thorough  trial  ;  cheesy 
and  broken-down  tissues  should  be  carefully  removed ;  pus-cavities 
should  be  scraped  out  and  necrosed  or  carious  bone  got  rid  of  by 
chisel  and  Volkmann's  spoon.  As  a  retentive  apparatus  a  plaster  cast 
controlling  the  pelvis  and  both  thighs  down  to  the  knees  is  very 
suitable.  The  patient  should  be  constantly  kept  in  the  recumbent 
position. 

The  prognosis  of  this  disease  is,  as  a  rule,  very  unfavorable. 

The  Knee-joint. — Tuberculosis 
of  the  knee  has  many  characteristics 
in  common  with  hip-joint  disease. 
The  bone  is  the  starting-point,  as  a 
rule,  in  children,  while  the  synovial 
membrane  is  the  first  structure  to 
suffer  in  adults.  The  lower  end  of  the 
femur  is  most  frequently  the  seat  of 


Fig.  74. — Apparatus  for  treatment  of  sacro-iliac 
disease  (Jones). 


Fig.  75. — Patient  in  apparatus  (Jones). 


the  infection,  next  in  order  comes  the  head  of  the  tibia,  and  lastly  the 
patella. 

Symptoms. — Slight  pain,  or  disinclination  to  use  the  joint,  or  a  limp 
may  be  the  first  indication  of  the  disease.  The  pain  is  localized,  and 
tenderness  on  pressure  over  the  affected  portion  of  bone  can  often  be 
elicited.  As  the  arthritis  advances  the  condyles  appear  to  be  swollen — 
a  condition  which  has  given  rise  to  a  great  deal  of  discussion.  This 
swelling  is  not  in  the  bone  itself,  but  in  the  tissues  covering  it.     Rigidity 


1 62 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


and  atrophy  of  muscles  define  the  character  of  the  disease  here,  just 
as  at  the  hip.  Swelling  of  the  whole  joint  comes  sooner  or  later,  and 
so  characteristic  is  it  of  disease  of  the  knee  that  the  whole  disease  is 

often  spoken  of  as  "  white  swelling."  Effu- 
sion of  fluid  is  most  noticeable  on  either  side 
of  the  patella.  Flexion  is  a  symptom  of 
great  importance,  and  should  be  controlled 
by  early  treatment,  as  it  rapidly  increases 
and  is  sure  to  result  in  deformity  (Fig.  76). 
Pain  is  not  a  trustworthy  symptom.  It  may 
be  but  slight,  even  when  extensive  ostitis  is 
present,  and  it  may  be  felt  at  the  hip  or 
acetabulum  and  throw  the  surgeon  off  his 
guard. 

Treatment. — The  principles  of  treatment 
are  practically  the  same  as  already  stated  in 
speaking  of  the  hip.  Rest  can  be  very 
effectually  maintained  by  extension  and  the 
recumbent  posture.  Plaster  of  Paris  and  the 
use  of  crutches  can  be  resorted  to  when  the 
acute  symptoms  are  well  under  control  and 
the  patient  can  move  about  without  increas- 
ing the  pain.  When  the  fluid  distends  the 
joint  or  threatens  to  open  spontaneously, 
aspiration  or  incision  should  be  resorted  to 
with  the  view  of  avoiding  septic  infection. 
Injections  of  iodoform  should  have  a  fair 
trial ;  and  lastly,  when  every  other  means 
fail  and  the  joint  is  doomed  to  destruction,  resection  or  amputation  will 
have  to  be  considered.  Nor  should  operative  interference  be  too  long 
delayed :  when  there  is  clear  evidence  of  a  localized  ostitis  at  the  lower 
end  of  the  femur  or  head  of  the  tibia  the  removal  of  the  diseased  focus 
cannot  be  too  early  effected. 

A  grating  sound  when  the  bones  are  rubbed  together  would  indicate 
an  extensive  destruction  of  bone-tissue,  and  would  probably  call  for 
typical  resection,  while  old  standing  cases  with  long-continued  sup- 
puration, numerous  sinuses,  and  low  vitality  will  necessitate  amputation. 
The  Ankle-joint. — Tuberculosis  in  the  ankle  begins,  in  the 
majority  of  cases,  as  a  synovial  affection.  When  the  bone  is  the  pri- 
mary seat  of  disease,  it  may  be  looked  for  in  the  parts  of  the  articula- 
tion which  have  to  bear  the  weight  of  the  body,  especially  in  the 
astragalus,  the  upper  part  of  the  malleoli,  the  os  calcis,  and  the  tarsal 
bones.  In  some  cases  the  disease  starts  in  the  sheaths  of  the  tendons 
crossing  the  joint. 

Symptoms. — When  the  disease  begins  in  the  synovial  membrane  the 
early  symptoms  are  stiffness,  slight  pain,  and  later  a  fulness  of  the 
joint,  particularly  in  front  outside  the  flexor  tendons  and  at  the  sides 
behind  the  malleoli.  In  the  osseous  variety  pain  is  likely  to  be  a 
marked  symptom,  and  a  localized  ostitis  may  be  recognized  at  an  early 
period  as  manifested  by  tenderness  on  pressure.  Swelling  comes  later, 
and  gives  the  idea  of  an  increase  in  the  thickness  of  the  bones.     The 


Fig.  76. — Tuberculosis  of  the 
knee-joint  (from  a  photograph  in 
the  collection  of  Dr.  Gillette). 


INJURIES  AND   DISEASES   OF  JOINTS.  1 63 

joint  gradually  takes  on  the  globular  shape,  the  skin  becomes  glossy 
and  white  or  red  from  congestion,  and  the  foot  assumes  the  position  of 
plantar  flexion. 

Treatment. — Immobilization  should  be  resorted  to  as  soon  as  a 
diagnosis  can  be  made.  Plaster  of  Paris  is  a  suitable  appliance,  care 
being  taken  to  place  the  foot  at  a  right  angle  to  overcome  the  tendency 
to  plantar  flexion  just  mentioned.  When  the  starting-point  is  a  local- 
ized ostitis,  an  incision  should  be  made,  the  diseased  focus  removed 
by  gouge,  chisel,  and  Volkmann's  spoon,  the  cavity  packed  with 
iodoform  gauze  and  allowed  to  heal  by  the  open  method.  Injections 
of  iodoform  emulsion  are  indicated  especially  when  the  synovial  mem- 
brane is  prominently  affected.  When  there  is  extensive  destruction 
of  the  articulation  resection  is  the  proper  course. 

The  Shoulder-joint. — The  synovial  membrane  is  the  first  struc- 
ture to  suffer.  When  the  affection  begins  in  bone  it  is  the  upper 
epiphysis  of  the  humerus.  Pain  is  not  so  prominent  a  symptom  as 
in  other  joints,  and  the  disease  may  terminate  in  bony  ankylosis  with 
comparatively  little  suffering.  Impaired  movement,  especially  that 
which  requires  elevation  of  the  arm,  muscular  wasting,  especially  of 
the  deltoid  and  supraspinatus,  are  the  early  symptoms,  with  localized 
tenderness  on  pressure  when  the  bone  is  affected.  Suppuration  is  not 
so  common  as  in  other  joints. 

Treatment. — The  joints  of  the  upper  extremity  are  more  amenable 
to  treatment  than  those  of  the  lower,  for  the  following  reasons :  They 
do  not  have  to  sustain  the  weight  of  the  body ;  they  are  smaller  artic- 
ulations ;  and  they  can  be  more  easily  immobilized  without  confining 
the  patient  to  bed.  The  treatment  is  immobilization  by  plaster  of  Paris 
to  control  all  movements,  even  to  the  fingers.  When  abscesses  form 
they  are  likely  to  point  in  the  axilla  and  should  be  treated  by  incision 
and  drainage.  When  the  head  of  the  bone  is  destroyed  resection  of 
the  joint  becomes  necessary — an  operation  which  has  afforded  encour- 
aging results. 

The  Hlbow-joint. — The  characters  of  tuberculosis  in  this  joint 
are  so  well  marked  that  diagnosis  is  not  difficult.  Children  and  young 
adults  form  the  majority  of  the  patients,  and  the  synovial  membrane  is 
the  structure  first  affected.  The  early  symptoms  are — a  fulness  on 
either  side  of  the  triceps  tendon,  wasting  of  the  muscles,  and  gradually 
increasing  flexion  of  the  joint.  As  the  disease  progresses  the  elongated 
spindle-shaped  swelling  involves  the  elbow ;  pronation  and  supination 
of  the  forearm  are  lost,  the  patient  making  awkward  attempts  to  replace 
these  movements  by  rotation  at  the  shoulder.  While  the  swelling  is  at 
first  firm  and  gelatinous,  it  eventually  breaks  down  and  liquefies  ;  the 
skin  becomes  thin  and  sinuses  form,  followed  by  long-continued  sup- 
puration. 

Treatment. — Perfect  and  long-continued  rest  in  a  position  of  flexion 
gives  good  results.  When  possible  the  joint  should  be  maintained  at 
a  right  angle  from  the  first  or  gradually  brought  to  that  position  as  the 
patient  can  bear  it.  When  suppuration  takes  place,  a  plaster-of-Paris 
cast  with  fenestra  for  dressing,  irrigation,  and  drainage  should  be  em- 
ployed. In  far-advanced  disorganization  of  the  joint  resection  should 
be  practised,  as  the  results   in   this  articulation  are  more  satisfactory 


164  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

than  in  any  other,  ahnost  perfect  movement  bcin^  acquired  in  favorable 
cases. 

The  Wrist-joint. — The  diagnosis  of  tuberculosis  of  the  wrist 
seldom  presents  any  difficulty.  It  commonly  is  an  extension  of  dis- 
ease from  the  carpal  bones  or  a  sequel  of  teno-synovitis.  Its  progress 
is,  as  a  rule,  more  rapid  than  is  the  case  with  other  joints.  It  is  found 
in  children  and  adults,  and  frequently  in  persons  beyond  middle  life. 
The  motions  of  the  joint  are  restricted  and  painful  at  an  early  period  ; 
atrophy  of  the  muscles  and  swelling  of  the  joints  are  marked,  giving 
the  hand  an  elongated  appearance. 

Trcatjucnt. — The  general  principles  of  tuberculosis  as  described  in 
other  joints. 

The  Phalangeal  Joints. — These  are  not  often  affected.  From  a 
diagnostic  point  of  view  disease  here  is  important,  owing  to  its  resem- 
blance to  syphilitic  dactylitis.  The  history  of  the  case  is  generally 
sufficient  to  decide  the  question,  and  should  any  doubt  exist  a  io-Vf 
weeks  of  antisyphilitic  treatment  will  settle  it. 

Rheumatic  Arthritis. — Acute  rheumatic  arthritis  is  a  medical 
rather  than  a  surgical  disease,  and  is  fully  dealt  with  in  works  on  the 
practice  of  medicine.  The  symptoms  are  very  characteristic  when  a 
number  of  joints  are  simultaneously  affected,  but  when  only  one  joint 
is  the  seat  of  disease  it  may  be  a  serious  question  to  decide  between 
rheumatism  and  osteo-arthritis.  This  monoarticular  form,  however,  is 
very  rare.  The  attack  may  begin  with  a  single  joint,  but  others  soon 
become  involved,  while  perhaps  the  symptoms  subside  in  those  pri- 
marily affected. 

The  symptoms  are  those  of  acute  synovitis.  Pain  is  unbearable  on 
the  slightest  movement.  Swelling  is  marked,  but  suppuration  rarely 
takes  place.  The  arthritis  subsides  with  the  termination  of  the  general 
disease. 

Chronic  rheumatic  arthritis  may  be  a  sequel  of  the  acute  form  or 
may  come  on  insidiously  as  a  result  of  cold  or  exposure.  It  has 
many  of  the  characters  of  chronic  synovitis  due  to  other  causes,  but 
there  is,  in  addition,  a  tendency  to  tissue-changes  which  are  peculiar  to 
this  variety.  The  synovial  membrane  is  thickened  and  produces  a 
creaking  sound.  Plastic  exudation  takes  place,  producing  a  thickening 
of  all  the  periarticular  tissues  and  leaving  the  joint  permanently  enlarged. 

Treatment. — According  to  the  stage  of  the  affection  the  joint  should 
be  treated  on  the  principles  already  laid  down.  In  chronic  cases  con- 
stitutional treatment  may  with  advantage  be  supplemented  by  baths, 
friction,  and  massage. 

Gonorrheal  Arthritis  (Gonorrheal  Rheumatism). — What  has 
been  long  considered  as  rheumatism  in  connection  with  gonorrhea  is 
more  properly  regarded  as  arthritis.  It  occurs  in  different  forms — as 
simple  intermittent  arthralgia,  as  a  chronic  inflammation  with  copious 
effusion  into  the  synovial  sac  (hydrops  articuli  or  hydrarthrosis),  as  a 
sero-plastic  arthritis,  and  as  a  suppurative  disease  of  the  joint.  Which- 
ever of  these  forms  is  manifested,  the  knee  is,  in  a  large  majority  of 
cases,  the  articulation  to  suffer.  Although  many  authors  state  that  this 
affection  is  often  connected  with  any  irritation  of  the  urethra,  such  as 
might  be  caused  by  the  simple  passing  of  a  catheter,  it  is  doubtful  if  it 


INJURIES  AXD  DISEASES   OF  JOINTS.  1 65 

ever  really  exists  without  the  presence  of  the  gonococcus  of  Neisser. 
The  persistence  with  which  these  germs  lie  dormant  in  the  urethra 
renders  it  probable  that  when  an  arthritis  is  set  up  by  the  passage  of  a 
catheter  it  is  an  auto-infection  from  latent  gonococci  or  their  ptoma'ins. 
Apart  from  the  symptoms  common  to  arthritis  due  to  any  other 
cause,  some  special  characters  are  to  be  noted : 

1.  In  the  acute  form  the  pain  is  intense,  worse  at  night,  and  espe- 
cially on  movement.  Atrophy  of  the  muscles  takes  place  rapidly ;  the 
febrile  symptoms  run  high,  causing  loss  of  strength  and  weight  at  an 
early  period.     Fibrous  ankylosis  is  a  common  result. 

2.  In  the  chronic  form  pain  may  be  absent  almost  throughout, 
while  at  the  same  time  the  joint  may  be  greatly  distended.  Suppura- 
tion is  rare. 

Neuropathic  Arthritis,  or  Charcot's  Disease. — This  is  an 
osteo-arthritis  observed  in  patients  suffering  from  locomotor  ataxia,  and 
first  described  by  Charcot  in  1868.  The  disease  is  due  to  changes  in 
the  spinal  cord,  probably  the  anterior  cornua.  The  following  are  its 
special  features:  (i)  Pain  and  constitutional  disturbance  are  frequently 
wanting.  (2)  The  destruction  of  the  joint-tissue  is  fearfully  rapid. 
Not  only  is  the  articular  end  of  the  bone  destroyed,  but  a  considerable 
portion  of  the  shaft  may  come  away  in  fragments.  The  ligaments 
break  down  and  favor  pathological  dislocation.  Grating  of  the  eroded 
bones  may  be  easily  elicited  at  an  early  period.  (3)  The  knee  and 
other  large  joints  are  those  most  frequently  affected. 

Gouty  Arthritis. — Gouty  arthritis  has  very  characteristic  symp- 
toms and  is  easily  diagnosed.  No  period  of  life  can  be  strictly  said  to 
be  exempt,  but  the  rule  is  that  it  occurs  in  patients  about  middle  life 
or  after.  It  is  essentially  hereditary,  but  the  frequency  of  attacks  and 
their  severity  depend  very  much  upon  the  patient's  manner  of  living. 
The  smaller  joints  are  those  most  frequently  affected,  and  especially 
the  ball  of  the  great  toe,  the  metatarso-phalangeal.  The  disease  may 
be    acute  or  chronic. 

1.  Acute. — The  type  of  inflammation  is  a  synovitis  attended  with  a 
turbid  effusion  of  serum  containing  urate  of  soda. 

Syuiptoms. — The  patient  may  or  may  not  have  warning  of  an 
impending  attack  by  a  feeling  of  malaise  lasting  for  several  days.  The 
first  local  symptoms  come  on  suddenly  at  night,  with  intense  pain  in 
the  affected  joint,  generally  the  great  toe.  The  part  is  exquisitely 
sensitive,  the  weight  of  the  bed-clothes  becomes  intolerable,  and  the 
pain  is  described  as  that  caused  by  a  red-hot  iron.  The  skin  is  red  or 
dusky  red,  congested,  and  hot;  the  parts  at  and  about  the  joint  are 
swollen  and  edematous.  The  constitutional  disturbance  is  generally 
slight.  In  cases  of  moderate  severity  the  pain  subsides  toward  morn- 
ing, the  swelling  disappears,  and  the  joint  is  probably  as  well  as  before. 
In  severe  forms  the  attack  returns  night  after  night  for  perhaps  a  week 
or  more. 

2.  Chronic. — The  symptoms  here  not  so  marked,  but  the  structural 
changes  are  greater.  Mobility  is  impaired,  and  deformity  exists  to  a 
greater  or  less  extent.  The  deposits  of  urate  of  soda  give  the  disease 
its  special  feature.  They  are  called  chalk-stones  or,  more  learnedly, 
tophi,  and  you   may  look  for  them  beneath  the  skin  at  the  smaller 


1 66  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

joints.  The  hands  arc  often  affected,  giving  the  knuckles  an  enlarged 
appearance.  The  gouty  old  whistplayers  of  England  were  in  the 
habit  of  utilizing  their  chalky  knuckles  to  mark  the  score  of  the  games 
on  the  card-table.  The  urine  is  usually  loaded  with  uric  acid,  the  skin 
is  predisposed  to  eczema,  and  the  throat,  tongue,  and  pillars  of  the 
fauces  are  smooth  and  glossy. 

Trcatuioit. — In  the  acute  form  rest,  with  a  local  application  for  the 
relief  of  pain.     The  following  has  been  extensively  used  : 

^.  Atropin,  gr.  j ; 

Morphin,  gr.  viij ; 

Aqua,  Sj. 

A  piece  of  lint  soaked  in  this  lotion  is  laid  over  the  inflamed  joint, 
covered  with  oiled  silk  and  absorbent  cotton.  The  constitutional 
treatment  for  gout  must  also  be  carried  out. 


CHAPTER   VI. 

INJURIES   AND    DISEASES   OF   THE   DIGESTIVE  SYSTEM. 

I.  THE   LIPS,  PALATE,  JAWS   AND  QUHS,  TONSILS,  PHARYNX,  AND 

ESOPHAGUS. 

The  Lips. 

The  surgery  of  the  lips  embraces  a  consideration  of  malformations, 
inflammations,  morbid  growths,  and  wounds. 

Hare-lip  is  by  far  the  most  frequent  of  the  malformations  of  the 
face,  and  depends  upon  a  congenital  failure  of  union  of  the  mesial 
nasal  process  with  that  of  the  superior  maxilla.  It  derives  its  name 
from  the  resemblance  to  the  cleft  which  exists  in  the  upper  lip  of  the 
hare,  rabbit,  and  other  allied  animals  ;  but  the  analogy  between  this 
defect  in  the  human  lip  and  the  normal  conformation  is  not  strictly 
correct,  the  cleft  in  the  latter  being  exactly  in  the  median  line,  while 
in  the  child  it  is  to  one  side  of  the  center.  It  is  often  associated  with 
club-foot  and  other  congenital  malformations. 

The  face  is  developed  partly  from  a  central  process,  \\\&  fronto-nasal 
plate,  descending  from  the  front  of  the  cranium  between  the  ocular 
vesicles.  From  this  are  developed  the  prominent  part  of  the  nose,  the 
septum  nasi,  the  columna,  the  central  part  of  the  upper  lip,  and  the 
intermaxillary  bone  with  the  incisor  teeth.  The  remainder  of  the  face 
above  the  line  of  the  lower  jaw  is  developed  from  a  lateral  process  on 
each  side,  the  superior  maxillary  plate,  which  gradually  grows  forward 
till  it  coalesces  with  the  vertical  process  just  mentioned.  From  these 
processes  are  developed  the  cheeks  and  the  whole  of  the  superior 
maxillary  bone,  except  the  part  of  the  palate  corresponding  to  the 
incisor  teeth,  which,  as  already  stated,  is  formed  from  the  fronto-nasal 


INJURIES  AND   DISEASES   OF   THE   DIGESTIVE   SYSTEM.        1 6/ 

plate.  The  lower  jaw  and  the  soft  parts  covering  it  are  formed  from 
similar  processes,  the  inferior  maxillary  plates  advancing  from  each 
side  and  coalescing  in  the  middle  line.  The  superior  and  inferior 
maxillary  plates  coalesce  at  each  side,  leaving  the  open  space  of  the 
mouth  in  the  middle  line.  The  mode  of  origin  of  the  various  deformi- 
ties of  the  face  is  therefore  evident.    If  one  maxillary  plate  fails  to  unite 


Fig.  77. — Double  hare-lip  be-        Fig.  78. — Single  hare-lip  be- 
fore operation  (Graham).  fore  operation  (Graham). 

with  the  naso-frontal  in  front,  a  cleft  will  be  left  through  the  upper  lip 
on  one  side  of  the  middle,  forming  a  single  or  simple  hare-lip  (Fig. 
78) ;  if  both  plates  fail  to  unite,  a  double  hare-lip  results  (Fig.  yj),  and 
the  intermaxillary  bone  may  be  left  adherent  to  the  tip  of  the  nose 
and  septum  nasi  (Fig.  81). 


Fig.  79. — Double  hare-lip  after     FiG.   80. — Single  hare-lip  after 
operation  (Graham).  operation  (Graham). 

If  at  the  same  time  the  development  of  the  naso-frontal  process  is 
arrested,  we  get  the  rare  condition  of  a  wide  gap  in  the  middle  line, 
with  absence  of  the  incisor  portion  of  the  upper  maxilla.  If  the  ante- 
rior parts  unite,  but  development  is  arrested  posteriorly,  cleft-palate 
results,  the  fissure  being  single,  and  in  the  middle  line  as  far  as  the 
posterior  part  of  the  premaxillary  bone. 

If  both  sides  fail  to  unite  completely,  the  fissure  is  single  behind 
and  double  in  front,  passing  on  each  side  of  the  intermaxillary  bone. 
In  exceedingly  rare  cases  the   fissure  of  the   hare-lip  has  been  seen 


1 68 


SURGICAL    DIAGNOSIS  AND    TREATMENT. 


extending  upward  on  one  side  of  the  nose  toward  the  eye.  The  cleft 
in  the  Hp  may  be  single  or  double.  The  proportion  of  single  is  about 
nine  for  one  that  is  double. 

The  diagnosis  of  hare-lip  is  simple.  In  the  examination  of  a  case 
note  whether  the  cleft  is  single  or  double,  whether  it  is  confined  to  the 
soft  parts  or  involves  the  bony  structures.  When  single,  the  fissure  is 
to  one  or  the  other  side  of  the  middle  line,  and  more  frequently  to  the 
left.  In  the  cleft  itself  the  mesial  side  of  the  gap  is  usually  rounded  ;  the 
outer  edge  is  flattened  and  the  frenum  at  the  angle  is  long  and  sub- 
cutaneous. 

The  cleft  generally  extends  upward  into  the  corresponding  nares, 
the  inner  side  of  the  chasm  being  continuous  with  the  septum  narium ; 

the  other  with  the  alae  nasi, 
making  an  uninterrupted  com- 
munication between  the  oral 
fissure  and  cavity  of  the  nose. 
The  mucous  membrane  of  the 
jaw  covers  both  sides  of  the 
gap.  When  double  hare-lip 
exists  it  is  likely  to  be  compli- 
cated with  cleft- palate  (Fig.  8i). 
Treatment. — The  only  treat- 
ment is  operative.  This  should 
be  resorted  to  at  an  early  period. 
The  time  chosen  must  depend 
upon  the  strength  of  the  child 
and  the  severity  of  the  necessary 
operation.  In  a  vigorous  infant 
with  a  single  hare-lip  it  can  be 
done  in  a  few  days  after  birth. 
As  a  general  rule,  however,  from 
the  sixth  to  the  twelfth  week 
will  be  the  most  suitable  time. 
In  complicated  cases  of  sim- 
ple cleft  it  is  better  to  wait  for 
four  or  five  months. 

An  endless  variety  of  opera- 
tions has  been  invented.  The  principles  which  have  to  be  kept  in  view 
are  to  remove  by  a  clean  incision  the  edges  of  the  cleft ;  to  separate  the 
lip,  and  if  necessary  a  part  of  the  cheek  from  its  attachment  to  the  jaw  ; 
to  bring  the  edges  into  close  apposition ;  to  unite  them  by  means  of 
sutures  or  hare-lip  needles  without  tension.  The  most  important  point 
is  to  guard  against  a  notch  at  the  vermillion  border  of  the  lip,  and  this 
is  accomplished  by  leaving  a  redundancy  of  tissue  at  the  lower  end  of 
the  fissure,  as  seen  in  Fig.  82. 

Operation. — The  patient,  having  been  anesthetized,  is  wrapped  in  a 
sheet  to  restrain  the  arms,  and  held  on  the  lap  with  the  child's  head 
resting  against  the  assistant's  chest.  The  lip  is  then  freely  separated 
from  the  gums  and  from  the  deeper  parts  of  the  cheek,  so  that  the 
cleft  can  be  closed  without  the  slightest  tension.  This  is  best  done 
with  scissors  curved  on  the  flat,  care  being  taken  to  keep  close  to  the 


Fig.  81. — Double  hare-lip  with  cleft  of  hard 
palate  and  cleft  of  intermaxillary  bone  (from  a 
photograph  in  the  collection  of  Dr.  C.  H.  Mayo, 
Rochester,  Minn.). 


INJURIES  AiVD   DISEASES   OF   THE   DIGESTIVE   SYSTEM.         169 


bone.  One  side  of  the  cleft  is  next  transfixed  with  a  sharp,  narrow- 
bladed  knife,  beginning  well  up  in  the  angle  and  cutting  downward  in 
the  arc  of  a  circle  the  concavity  of  which  is  directed  toward  the  middle 
line.     The  strip  may  be  left  attached  at  its  lower  end,  and  afterward 


Fig.  82. — Operation  for  single  hare-lip  (after  Malgaigne). 

made  use  of  to  fill  the  notch  which  may  be  left  when  the  parts  are 
brought  together.  Both  sides  of  the  cleft  having  been  pared  alike,  the 
raw  surfaces  are  brought  together,  care  being  taken  that  a  little  pro- 
jection is  left  at  the  lower  end  of  the  united,  fissure.  This  projection 
contracts  during  the  process  of  healing  and  guards  against  the  forma- 
tion of  an  unseemly  notch.  Bleeding,  if  severe,  is  arrested  by  the 
pressure  of  hemostatic  forceps  gently  applied  to  the  whole  thickness 
of  the  lip  or  by  the  gentle  pressure  of  the  lip  between  the  thumb  and 
fore  finger  of  an  assistant.  The  blood-supply  will  be  considerably 
lessened  by  the  assistant's  making  pressure  upon  the  facial  arteries  as 
they  wind  around  the  lower  jaw.  The  parts  accurately  fitted  are  next 
held  together  by  silkworm-gut  sutures.  The  upper  stitch  is  inserted 
first  to  close  the  angle,  and  the  two  or  three  others  to  close  the  remain- 
der of  the  cleft.  The  vermillion  border  will  generally  require  a  fine 
catgut  suture.  Hare-lip  pins  are  still  employed  by  many  surgeons,  but 
silkworm  gut  fulfils  every  indication. 

The  simplest  dressing  is  a  coating  of  iodoformized  collodion.  To 
lessen  the  strain  on  the  stitches  a  piece  of  adhesive  plaster  can  be 
stretched  from  cheek  to  cheek.  In  ordinary  cases  the  sutures  can  be 
removed  about  the  fifth  day. 

Double  hare-lip  requires  practically  the  same  treatment.  The 
central  portion  must  be  pared  in  the  same  manner  as  the  borders  of 
the  cleft.  When  this  central  portion  is  too  narrow  to  be  of  any  use  in 
filling  up  the  gap,  it  is  best  to  remove  it  and  treat  the  case  as  one  of 
single  hare-lip.  In  some  cases  the  central  portion  is  short  and  only 
helps  to  fill  the  upper  part  of  the  cleft, 
while  the  sections  removed  from  the 
sides  of  the  fissure  are  made  to  meet 
in  the  middle  line  below  (Fig.  83). 

Protrusion  of  the  intermaxillary 
bone    is    a   complication    of  double 
^hare-lip  that  requires  special  atten- 
tion.   The  projecting  bone  should  be 
preserved  if  possible — not  that  the 

bone  does  much  good  or  that  the  incisor  teeth  which  grow  from  it  are 
likely  to  be  fully  developed,  but  its  removal  leaves  the  lip  without  sup- 
port and  causes  an  unsightly  appearance.       In  many  cases  the  pro- 


FlG. 


83. — Operation    for    double    hare-lip 
(Keen  and  White). 


170 


SC'RGICAL   D/AGjyOSIS  AND    TREATMENT. 


jection  can  be  pressed  back  into  position  either  by  the  finger  and 
thumb  of  the  operator  or  by  the  aid  of  forceps  covered  with  rubber. 
When  replaced  the  bone  should  be  fixed  in  position  by  chromicized 
catgut,  as  the  least  pressure  forward  will  interfere  with  the  healing  of 
the  lip.  There  may  be  cases  in  which  it  will  be  found  advisable  to 
correct  this  deformity  and  then  wait  a  week  or  two  before  operating  on 
the  lip.  When  the  deformity  is  such  that  the  projecting  portion  cannot 
be  returned,  tlie  bony  structure  should  be  removed,  saving  the  perios- 
teum and  soft  parts  to  help  in  maintaining  the  shape  of  the  lip. 

Fissures  of  the  lower  lip  are  very  rare,  only  three  or  four  cases 
being  on  record.  The  fissure  is  in  the  mesial  line,  and  the  treatment  is 
the  same  as  that  required  in  simple  cleft  in  the  upper  lip. 

Macrostotna  is  a  deformity  in  which  the  opening  between  the  lips 
is  abnormally  large.  It  is  either  congenital,  resulting  from  non-union 
of  the  superior  and  inferior  maxillary  plates,  or  the  result  of  a  wound 
which  has  imperfectly  healed.  In  either  case  the  treatment  consists  in 
freshening  the  edges  and  uniting  them  by  sutures. 

Microstoma  is  the  opposite  condition,  in  which  the  opening  to  the 
mouth  is  abnormally  small.  In  some  cases  the  opening  of  the  lips  is 
so  much  contracted  as  to  interfere  with  the  introduction  of  food  into 
the  mouth.  It  may  be  caused  by  the  cicatricial  contraction  w'hich 
follows  burns  and  ulcers  or  it  may  be  congenital.  The  treatment  con- 
sists in  extending  the  opening  to  a  sufficient  length  toward  the  cheeks 


'^.M^^H 

% 

pR 

m- 

ft  ^B.          -SMMtft^L. 

J 

Uss-.' 

1  w.  ■■ 

r-^m 

i 

' 

H 

'H 

^:_.,„^| 

Fig.  84.- 


-Deformity  resulting  from  a  burn  five  years  unhealed  (from  a  photograph  in  the  col- 
lection of  Dr.  Lincoln). 


and  attaching  skin  and  mucous  membrane  by  fine  sutures.  When  the 
tissues  are  very  much  consolidated  by  cicatricial  contraction  there  will 
be  difficulty  in  maintaining  the  opening,  and  it  will  be  necessary  to 
stretch  the  parts  mechanically  and  maintain  the  dilatation  for  a  long 
period.  A  still  greater  congenital  defect  is  total  closure  of  the  anterior 
buccal  orifice  (atresia  oris). 


INJURIES  AND   DISEASES   OF   THE   DIGESTIVE   SYSTEM.        171 

The  treatment  consists  in  making  an  artificial  opening  by  a  longi- 
tudinal incision  and  suturing  the  mucous  membrane  to  the  skin,  so  as 
to  give  the  normal  vermillion  border  to  the  lips.  The  cicatrices  result- 
ing from  burns  about  the  face  and  neck  often  produce  unsightly  deform- 
ities, drawing  down  the  corners  of  the  mouth  or  causing  eversion  of  the 
lips  (Fig.  84).  A  preternatural  length  of  frenum  labii  will  also  give  rise 
to  eversion. 

Cases  of  this  kind  require  for  treatment  the  removal  of  the  cicatrix 
and  the  substitution  of  healthy  integument  from  an  adjacent  part. 

If  the  defect  be  due  to  a  long  frenum,  the  removal  of  a  V-shaped 
piece  from  this  fold  and  permitting  it  to  heal  by  granulation,  in  order 
to  obtain  the  benefit  of  some  cicatricial  shortening,  is  indicated. 

Nevi  of  the  lips  are  usually  congenital.  The  minute  vessels  of  the 
mucous  membrane  or  of  the  skin,  or  of  both  structures  combined,  may 
be  involved,  and  when  limited  to  the  cutaneous  surface  of  the  lip  the 
growth  appears  as  a  small  red  or  purple  spot.  When  located  in  the  mu- 
cous surface  it  is  recognized  as  a  soft,  spongy,  vascular  mass  appearing 
on  the  inner  surface  of  the  lip,  having  a  bluish  or  purplish  color,  which, 
in  cases  affecting  the  whole  thickness  of  the  lip,  is  visible  through  its 
cutaneous  surface.  The  tumor  enlarges  during  excitement,  as  in 
laughing  or  crying,  and  can  be  deprived  of  most  of  its  blood  by  com- 
pression, leaving  an  apparently  empty  sac.  These  vascular  tumors 
increase  with  the  growth  of  the  child,  and  the  earlier  they  are  removed 
the  better ;  they  may  extend  to  the  cheeks. 

In  many  cases  the  disease  is  very  limited  in  extent,  and  then  should 
be  excised  and  the  edges  of  the  wound  united  with  fine  catgut  or 
horse-hair  sutures.  When  more  extensive  the  growth  may  be  trans- 
fixed by  two  needles  placed  at  right  angles  and  surrounded  by  a  liga- 
ture drawn  sufficiently  tight  to  arrest  circulation,  or  the  growth  may 
be  strangulated  by  multiple  ligatures  placed  at  right  angles  to  each 
other. 

Electrolysis  is  another  method  employed  when  the  nevus  is  large. 
Two  or  three  needles  are  passed  into  its  interior  and  connected  with 
the  negative  pole  of  a  battery.  Another  needle  is  introduced  into  the 
growth  and  attached  to  the  positive  pole.  In  a  short  time  the  tissue- 
destruction  which  is  in  progress  within  the  tumor  will  be  indicated  by 
little  bubbles  of  gas  which  make  their  way  by  the  side  of  the  needles. 
Coincident  with  this  the  blood  in  the  growth  undergoes  coagulation, 
and  the  mass  is  absorbed  and  gradually  disappears. 

Other  tumors  found  in  the  lips  are  the  following : 

{a)  Cysts  are  caused  by  the  distention  of  the  labial  follicles  due 
to  the  destruction  of  the  excretory  ducts.  Small  cysts  are  treated 
by  laying  open  the  sac,  turning  out  the  contents,  and  cauterizing  the 
cavity  with  nitrate  of  silver.     If  large  they  should  be  excised. 

{b)  I/ipomata,  or  fatty  tumors,  are  exceptionally  rare. 

{c)  Myxomata  are  quite  uncommon,  and  are  found  in  the  sub- 
mucosa,  and  are  filled  with  a  yellow,  gelatinous  fluid.  Excision  is  the 
proper  treatment. 

(c/)  Adenomata,  a  new  formation  of  the  glandular  elements  of  the 
lip,  forming  a  tumor,  are  very  rare.     Excision  is  the  remedy. 

{e)  Sarcomata. 


172  SL'RG/CAL    D/AGXOS/S   AXD    'IKKATMEXT. 

(/")  Fibromata,  occurrintj^  as  hard,  florid,  pedunculated  enlarge- 
ments, slow  of  growth  and  insensible  to  pressure. 

Trcatmctit. — Kxcision,  except  perhaps  papilloniata,  which  may  be 
destroyed  by  caustics  if  of  the  soft  or  mucous  kind,  but  if  of  the 
corneous  variety  they  should  be  excised. 

Furuncle  and  carbuncle  are  sometimes  found  on  the  lips.  They 
are  s]:)cciall)'  im])ortant  from  the  clinical  fact  that  they  are  often 
attended  with  sejjtic  symptoms,  believed  to  be  due  to  absorption  by  the 
facial  vein.  They  are  exceedingly  painful,  and  often  produce  cerebral 
symptoms  which  have  been  known  to  prove  fatal. 

The  treatment  consists  in  early  free  incision  through  the  free  border 
of  the  lip,  followed  by  antiseptic  dressing. 

Hypertrophy  of  the  lips  is  quite  common  in  a  moderate  degree, 
and  requires  no  attention,  but  cases  are  occasionally  met  with  in  which 
the  overgrowth  is  a  very  trying  deformity.  One  or  both  lips  may  be 
affected  and  the  hypertrophy  may  be  partial  or  general.  The  partial 
form  of"  double  lip,"  as  it  is  sometimes  called,  consists  in  a  redundancy 
of  the  mucous  membrane  and  submucous  tissue,  and  usually  more 
prominent  on  either  side  than  at  the  middle  line.  It  is  sometimes  so 
marked  as  to  interfere  with  the  function  of  the  lips,  and  is  always 
unsightly. 

The  treatment  consists  in  the  removal  of  a  longitudinal  wedge- 
shaped  piece  of  the  redundant  tissue  and  the  closing  of  the  wound 
with  sutures. 

Wounds  of  the  lips  bleed  freely,  but  hemorrhage  is  readily 
checked  by  grasping  the  thickness  of  the  lip  betw^een  the  finger  and 
thumb  or  by  applying  forceps  to  the  bleeding  vessel.  Sutures  which 
approximate  the  edges  of  the  wound  will  also  arrest  the  hemorrhage. 
In  suturing  a  wound  of  the  lip  the  greatest  care  should  be  taken  to 
ensure  accurate  approximation,  and  thus  avoid  uneven  surfaces  after 
healing  has  taken  place. 

Inflammation. — Chapped  or  cracked  lips  are  troublesome  affec- 
tions, particularly  during  the  winter  months.  In  a  diagnostic  sense 
they  are  of  little  importance,  except  that  a  fissure  which  continues  for 
a  long  time  should  excite  suspicion  of  commencing  epithelioma. 
Simple  fissures  or  chapped  lips  as  a  rule  heal  readily  when  protected 
by  court-plaster,  collodion,  or  ointment.  In  children  fissures  often 
appear  on  the  upper  lip,  and  are  frequently  attended  with  an  unhealthy 
discharge  from  the  nose  which  excoriates  the  skin  below,  with  tarsal 
ophthalmia,  enlarged  glands  in  the  neck,  and  signs  of  tuberculosis. 
Constitutional  treatment  is  here  indicated.  The  neglected  fissures  are 
apt  to  leave  clefts  which  cause  deformity,  and  should  be  remedied  by 
paring  the  edges  and  bring  them  accurately  together  by  horsehair 
sutures. 

When  cracks  are  observed  in  the  corners  of  the  mouth,  a  careful 
inquiry  should  be  made  into  the  case,  as  it  is  not  uncommon  to  find 
such  lesions  in  persons  suffering  from  constitutional  syphilis.  A 
neglected  chap  or  crack  or  one  which  has  been  irritated  by  smoking  is 
liable  to  degenerate  into  a  sore  or  ulcer  of  considerable  depth,  with 
irregular  edges,  and  with  unhealthy  granulations  which  bleed  at  the 
slightest  provocation,  as  in  wiping  the  mouth  or  in  chewing  food. 


INJURIES  AND   DISEASES   OE   THE   DIGESTIVE   SYSTEM        1 73 

Touching  the  sore  with  silver-nitrate  stick  and  protecting  with  col- 
lodion dressing  will  serve  to  ensure  its  repair.  Excision  and  closing 
with  sutures  may  have  to  be  resorted  to. 

Destructive  caustics  tend  to  leave  an  unsightly  depression. 

epithelioma. — This  is  a  very  common  disease  of  the  lower  lip 
occurring  in  males  beyond  middle  life.  In  its  early  stages  it  is  a  small 
persistent  ulceration  covered  with  a  scab,  and  supposed  by  the  patient 
himself  to  be  an  ordinary  chapped  lip,  or  the  growth  may  begin  as  a 
raised  papillomatous  surface  covered  with  epithelium,  or  as  a  crack  or 
fissure,  sometimes  as  a  small  shot-like  tubercle ;  but,  whatever  its 
initial  appearance,  it  is  always  surrounded  by  a  discoverable  degree  of 
submucous  induration.  By  degrees  the  ulcer  enlarges  and  deepens 
(Fig.  85)  and  is  surrounded  by  a  hardened  ring.     When  long  neglected 


FIG.  85.- 


-Epithelioiiia  of  lip  (from  a  photograph  in  the  collection  of  Dr.  Strickler,  New  Ulm, 

Minn.). 


the  glands  beneath  the  jaw  become  enlarged,  the  ulceration  becomes 
wider  and  deeper,  its  edges  hard,  irregular,  ragged,  and  covered  with 
fungous  granulations  which  bleed  on  being  handled.  The  sore  pours 
out  an  offensive  discharge,  and  the  patient  is  harassed  with  sharp  burn- 
mg,  lancinating  pains.  The  lip  is  destroyed,  nutrition  fails,  the  sufferer 
IS  unable  to  rest  without  the  aid  of  opiates ;  he  becomes  cachectic,  and 
death  at  last  comes  mercifully  to  his  relief 

The  only  disease  with  which  epithelioma  is  likely  to  be  confounded 
IS  chancre.  The  points  of  difference  are  the  following :  Cancer  of  the 
hp  occurs  in  males,  and  nearly  always  it  is  the  lower  lip.  The  lym- 
phatics are  not  affected  until  late  in  the  disease,  and  its  progress  is 
slow.     Chancre,  on  the  other  hand,  is  more  common  in  females  and  in 


174 


SURGICAL    DIAGNOSIS  AND    TREATMENT. 


yoLiiii:^  persons.  The  l\'ni[)haties  are  involved  at  an  early  period.  There 
are  sore  throat,  skin-eruptions,  and  otiier  manifestations  of  syphilis,  and 
constitutional  treatment  is  readily  responded  to.  An  ulceration  in  a 
man  past  middle  age  which  has  lasted  several  months  and  refuses  to 
heal  should  be  excised. 

Treatment. — Operation  for  the  comjjlete  removal  of  the  cancerous 
portion  is  the  only  treatment  to  be  thought  of,  and  if  resorted  to  before 
glandular  involvement  has  occurred,  the  results  are  very  satisfactory. 
In  ordinary  cases  the  V-shaped  incision  is  best,  care  being  taken  to  cut 
wide  of  the  disease.  In  advanced  cases  the  whole  lip,  and  even  a  part 
of  tile  jaw,  must  be  removed,  and  a  new  lip  formed  by  transplantation 
of  flaps  from  healthy  skin. 


The  Palate. 

Cleft-palate  is  a  malformation  very  frequently  met  with  in  con- 
junction with  double  hare-lip  (Fig.  86).     The  cleft  may  be  confined  to 

the  soft  palate  or  may  extend 
through  the  bony  palate  as  well. 
It  more  rarely  forms  a  complica- 
tion of  single  hare-lip,  and  may 
even  occur  in  children  whose  lips 
are  perfectly  formed.  The  signs 
of  cleft-palate  in  combination  with 
hare-lip  are  too  obvious  to  be 
overlooked,  but  when  it  occurs 
alone  it  may  escape  observation 
for  some  time.  The  first  intima- 
tion is  usually  given  when  the 
infant  attempts  to  take  milk  from 
the  breast  or  from  a  spoon,  with 
the  result  that  the  milk  escapes 
by  the  nostrils  instead  of  being 
swallowed.  In  some  cases  the 
nasal  character  of  the  infant's  cry 
is  sufficient  to  attract  attention  to 
the  deformity. 

The  perforations  in  the  palate 
produced  by  syphilis  cannot 
readily  be  mistaken  for  a  cleft. 
When  due  to  syphilis  the  open- 
ings in  the  soft  palate  are  not 
symmetrical ;  there  are  usually 
other  signs  of  the  specific  dis- 
ease, and  there  is  a  large  amount 
of  scar-tissue. 

Trcatvioit. — The  researches  of 
Dr.  Haughton  of  Dublin  have  proved  that  the  closure  of  the  hard 
palate  is  greatly  influenced  by  the  character  of  the  food.  A  mother 
who  shows  any  hereditary  tendency  or  who  has  borne  children  with 
this   deformity  should,  during  pregnancy,  keep  her  health   up  to  the 


Fig.  86. — Hare-lip  and  cleft-palate  (from  a 
photograph  in  the  collection  of  Dr.  C.  H.  Mayo, 
Rochester,  Minn.). 


INJURIES  AND   DISEASES   OF   THE   DIGESTIVE    SYSTEM.        1 75 

best  possible  condition,  and  should  partake  largely  of  foods  which 
tend  to  bone-formation.  When  the  cleft  is  in  the  palate  alone,  the 
nourishment  of  the  infant  is  a  matter  of  great  importance,  as  the 
danger  is  that  the  child  will  waste  away  for  want  of  nutrition.  A  flap 
attached  to  the  nipple  of  a  feeding-bottle  which  closes  the  cleft  while 
the  child  sucks  is  a  simple  and  useful  expedient.  A  long  nipple  with  a 
hole  in  its  lower  side  is  often  satisfactory,  as  also  feeding  the  child  by 
means  of  a  long-necked  bottle,  so  that  the  fluid  is  poured  at  the  back 
of  the  throat. 

Operative  treatment  affords  the  best  chance  of  repair,  and  has  taken 
the  place  of  silver  plates  formerly  in  vogue.  Much  difference  of  opin- 
ion has  existed  as  to  the  time  when  operation  should  be  resorted  to,  but 
the  following  points  may  be  taken  as  practically  settled : 

1.  When  there  is  hare-lip  complicating  cleft-palate  operate  as  early 
as  possible  upon  the  lip.  Several  objects  will  be  gained  by  this  course : 
The  closure  of  the  lip  will  help  the  child  to  suck ;  it  will  remove  a 
hideous  deformity,  and  thereby  lessen  the  burden  of  the  parents ;  and 
it  will  be  found  that  the  cleft  in  the  hard  palate  will  gradually  close  to 
a  considerable  extent.  The  tendency  of  the  two  sides  of  the  hard 
palate  to  approach  each  other  continues  for  several  years  after  birth, 
and  is  greatly  favored  by  the  closure  of  the  cleft  in  the  lip. 

2.  Closure  of  the  palate  should  not  be  undertaken  until  after  the 
first  dentition  or  about  the  end  of  the  second  year.  Most  children 
make  earnest  efforts  to  talk  about  this  period.  Should  the  operation 
be  delayed,  that  peculiar  nasal  twang  will  have  been  acquired  which  is 
so  difficult  to  unlearn  in  riper  years.  Some  surgeons  would  limit  ope- 
rations at  the  end  of  the  second  year  to  cleft  of  the  soft  palate  only, 
while  those  of  the  bony  palate  are  left  to  the  twelfth  year. 

In  estimating  the  probable  result  of  an  operation  much  depends 
upon  the  shape  of  the  palate.  Persons  with  highly  arched  but  healthy 
palates  are  observed  to  speak  with  a  nasal  twang.  Sir  William  Fergusson 
pointed  out  that  in  cases  of  highly  arched  palates  (resembling  a  Norman 
arch  in  section)  it  is  not  difficult  to  make  the  flaps  approximate,  but 
these  cases  are  often  disappointing  as  regards  the  power  of  speech 
which  the  patient  afterward  enjoys,  while  in  palates  with  a  slight  arch 
(Gothic  arch)  the  flaps  are  brought  together  with  much  greater  dif- 
ficulty, but  when  the  operation  is  successful  speech  is  much  better. 
Another  point  upon  which  success  largely  depends  is  the  length  of  the 
palate,  for  if  it  does  not  go  back  far  enough  to  shut  off  the  mouth  from 
the  nose,  the  person  will  speak  with  a  nasal  intonation.  This  point  is 
decided  in  this  manner :  Grasp  the  patient's  chin  and  hold  his  mouth 
open  while  you  ask  him  to  swallow.  If  in  the  act  of  swallowing  the 
edges  of  the  cleft  in  the  soft  palate  come  in  contact  throughout  their 
whole  length,  while  at  the  same  time  the  superior  constrictor  and 
palato-pharyngeal  muscles  closely  approximate  the  palate  and  pharynx, 
the  case  is  one  favorable  for  operation.  Union  may  with  certainty  be 
expected,  and   phonation  will  probably  be  satisfactory  (Heath). 

Operation. — Staphylorrhaphy  is  the  name  applied  to  the  operation 
for  closure  of  the  cleft  in  the  soft  palate.  It  is  an  old  operation,  having 
been  first  performed  by  a  Parisian  dentist,  Le  Monier,  in  1764.  As 
performed  at  the  present  day  it  is  done  as  follows :  The  patient,  well 


176 


SrHGICAL  DIAGNOSIS  AND    TREATMENT. 


under  the  influence  of  chloroform,  is  placed  upon  a  high  table  with 
the  head  turned  toward  the  right  side,  and  so  held  that  any  blood 
which  flows  will  not  gravitate  into  the  pharynx.  A  Whitehead  or 
other  suitable  gag  is  inserted  and  the  mouth  forced  open. 

First  Step. — The  end  of  one  side  of  the  cleft  is  seized  by  a  tenaculum 
forceps  and  held  tense,  while  a  thin-bladed  knife  cuts  a  narrow  strip 
along  the  side  of  the  cleft  and  up  into  the  angle  (Fig.  87).  The  other 
side  of  the  cleft  is  dealt  with  in  a  similar  manner,  care  being  taken  to 
go  well  up  into  the  angle  and  leave  a  clean-cut  surface  throughout. 


Fig.  87. — Freshening  the  margin  of  the 
cleft  in  the  operation  of  staphylorrhapliy 
(after  Malgaigne). 


Fig.  88. — Soft  palate  sutured,  with  lateral 
incisions  for  the  relief  of  tension. 


Second  Step. — The  placing  of  sutures.  Silver  wire,  chromicized 
catgut,  and  silk  have  been  used,  but  the  most  suitable  material  of  all 
is  probably  silkworm  gut.  Needles,  too,  of  various  kinds  have  been 
invented,  but  a  half-curve  Hagedorn  in  a  needle-holder  is  as  good  as 
any.  The  needle  should  be  inserted  about  three  lines  from  the  margin 
and  about  half  an  inch  from  the  angle  of  the  cleft.  Other  sutures  are 
passed  in  a  similar  manner  at  distances  of  half  an  inch  until  the  ends 
of  the  cleft  are  reached. 

Third  Step. — If  the  sutures  can  be  tied  without  producing  undue 
tension,  this  is  done  at  once,  and  the  operation  is  finished;  but  if  the 
strain  is  too  great  to  allow  the  parts  to  come  easily  together,  the 
tensor  palati  muscles  must  be  divided.  This  is  done  by  making  an 
incision  in  the  soft  palate  just  internal  to  the  hamular  process,  and 
cutting  upward  until  the  muscles  are  severed.  The  position  of  this 
incision  is  seen  in  Fig.  88.  The  stitches  should  be  removed  about  the 
eighth  day. 

Uranoplasty  is  the  name  of  the  operation  for  closure  of  the  hard 
palate,  and  the  method  of  Sir  William  Fergusson  is  generally  followed. 
The  edges  of  the  cleft  should  be  pared  as  in  staphylorrhaphy,  and 
sutures  inserted,  but  left  untied.  Midway  between  the  cleft  and  the 
alveolus  an  incision  is  made  through  the  soft  parts  down  to  the  bone. 


INJURIES  AND   DISEASES   OF   THE   DIGESTIVE   SYSTEM.        1 77 

By  means  of  a  chisel  the  bone  itself  is  next  cut  through,  and,  using  the 
chisel  as  a  lever,  the  bone  on  each  side  is  forced  toward  the  middle 
line  and  the  cleft  thus  obliterated.  The  sutures  are  now  tied  and  the 
lateral  incisions  packed  with  iodoform  gauze. 

Closure  of  the  hard  palate  may  be  effected  without  cutting  the  bone 
as  just  described.  Dr.  Mason  Warren  of  Boston  was  the  first  to  operate 
by  detaching  flaps  consisting  of  periosteum  and  mucous  membrane. 
The  edges  of  the  cleft  are  pared  as  in  the  preceding.  By  means  of  a 
periosteal  elevator  all  the  soft  parts  are  raised  from  the  hard  palate, 
care  being  taken  not  to  tear  the  arteries  passing  through  the  anterior 
and  posterior  palatine  canals.  The  soft  palate  is  cut  away  from  the 
horizontal  plate  of  the  palate-bone,  as  tearing  is  apt  to  produce  slough- 
ing. Sutures  are  now  placed  in  position,  but  not  tied.  If,  as  usually 
happens,  the  tension  on  the  stitches  is  too  great,  this  is  remedied  by 
making  an  incision  on  each  side  midway  between  the  sutures  and  the 
alveolar  border. 

The  after-treatment  in  all  these  operations  consists  in  thoroughly 
irrigating  the  mouth  with  mild  antiseptic  solutions,  such  as  boracic 
acid,  and  in  painting  the  incision  with  iodoformized  collodion.  Liquid 
food  should  be  given  for  three  or  four  days,  and  the  stitches  removed 
at  about  the  end  of  a  week.  Should  one  or  more  spots  have  failed  to 
unite,  they  can  be  touched  with  a  stick  of  nitrate  of  silver  or  by  the 
point  of  a  thermo-cautery. 

So  much  for  operations  as  they  are  generally  performed.  It  must 
be  granted  that  they  leave  a  great  deal  to  be  desired.  Waiting  for  the 
end  of  the  second  year  to  close  a  soft  palate  and  for  twelve  years  to 
close  a  cleft  in  the  bony  palate  is  tedious  and  unsatisfactory.  Muscles 
are  allowed  to  remain  inactive  and  to  atrophy  which  can  never  after- 
ward be  properly  developed,  and  as  a  consequence  it  is  rare  to  find  one 
of  these  patients  who  has  perfect  phonation.  The  crying  demand  is, 
then,  for  an  operation  that  will  close  the  cleft  in  early  infancy  and  allow 
the  patient  to  exercise  these  muscles  from  the  first.  Such  a  procedure 
will  prevent  the  acquiring  of  nasal  intonation  and  allow  the  child  to 
speak  naturally  from  the  beginning.  For  the  attainment  of  this  object 
the  operation  devised  and  practised  by  Dr.  Brophy  of  Chicago  deserves 
attention.  In  cases  of  cleft-palate  with  hare-lip  he  ad\'ocates  operating 
on  the  palate  first,  as  it  gives  better  access  to  the  mouth,  and  the  closure 
of  the  cleft  in  the  alveolar  process  is  better  accomplished  when  fully 
exposed  to  view  through  the  diseased  lip.  The  operation  is  thus 
described  by  Dr.  Brophy  : 

"  First,  place  the  patient  on  the  table  with  the  face  toward  the  light. 
Introduce  the  oral  speculum  and  vivify  the  edges  of  the  fissure ;  do  it 
thoroughly  and  with  a  bold  hand.  A  mere  scraping  of  the  mucous 
membrane  will  never  suffice  to  bring  about  union  which  will  be  per- 
manent and  satisfactory.  On  the  hard  palate  trim  the  opposing  sur- 
faces of  the  bone  as  well.  If  this  is  well  done,  it  will  secure  a  sufficient 
exudate  to  make  the  operation  a  successful  one,  in  this  respect  at  least. 
The  knife  will  easily  cut  through  the  soft  bone  of  the  hard  palate  and 
the  alveolar  process  of  young  patients.  Then  raise  the  cheek,  and  well 
back  toward  the  posterior  extremity  of  the  hard  palate,  just  back  of  the 
malar  process,  and  high  enough  to  escape  all  danger  of  not  being  above 
12 


178  SURGICAL   DIAGNOSIS  AND    7'KRATiMENT. 

tlic  palatal  plate  of  the  bone,  insert  a  large  braided  silk  suture,  carrying 
it  through  the  substance  of  the  bone,  so  that  it  will  come  out  at  a  corre- 
spoiuling  position  upon  the  opj)osite  side.  The  silk  suture  is  more  easily 
introduced  b)'  the  needle,  but  a  wire  suture  of  silver  should  be  substi- 
tuted for  it  and  drawn  through  in  its  place,  and  this  wire  may  be  doubled 
in  case  the  condition  of  the  parts  and  the  tension  upon  the  tissues  neces- 
sary to  approximate  them  seem  to  require  it. 

"  Nearer  the  front  portion  of  the  palate  insert  another  wire,  carrying 
it  through  the  substance  of  the  bone  above  the  palatal  plates,  and  out 
through  the  other  side  in  a  position  corresponding  to  the  place  of 
entrance.  Thus  we  shall  have  one  wire  passing  over  the  palate  in  front 
of  the  malar  process  of  the  bone  and  another  behind  it. 

"  The  next  step  is  to  take  a  lead  button,  moulded  to  fit  the  convexity 
of  the  part,  and  long  enough  to  pass  beyond  the  exit  of  the  wire 
sutures,  so  that  they  will  pass  through  it.  Have  it  provided  with  eye- 
holes, through  which  are  passed  the  protruded  ends  of  the  wire  upon 
each  side ;  twist  them  together — that  is,  the  right  end  of  the  anterior 
wire,  and  the  same  on  the  left.  It  is  good  practice  always  to  twist 
wires  in  one  way,  either  from  right  to  left  or  from  left  to  right.  These 
are  hea\'y-tensioned  sutures,  and  once  approximated  the  parts  cannot  be 
separated  by  the  patient.  If  from  lack  of  tissue  or  from  firm  resistance 
of  the  ])arts  the  fissure  cannot  be  closed  with  these  wires,  there  is  a 
further  method  to  be  employed  which  will  obviate  these  difficulties. 
With  your  knife,  after  the  cheek  is  well  raised,  divide  the  mucous 
membrane  just  over  the  malar  process.  Here  insert  a  knife  in  a  hori- 
zontal direction,  and  when  well  inserted  sweep  the  handle  around 
from  one  side  to  the  other,  as  from  behind  forw-ard.  In  this  way 
a  maximum  amount  of  bone  is  divided  and  a  minimum  amount 
of  the  mucous  membrane.  This  being  done  on  each  side,  the 
bone  can  very  readily  be  moved  toward  the  middle  line.  Having  thus 
divided  the  bones  on  either  side,  the  wire  sutures  passing  through  the 
lead  buttons  may  again  be  twisted,  and  the  cleft  of  the  hard  palate  will 
be  easily  closed  by  approximation  of  the  two  sides.  The  incision  in 
the  mucous  membrane  in  making  the  separation  of  the  bones  is  as 
small  as  possible,  for  the  reason  that  this  membrane  must  serve  to 
retain  the  bones  in  proximity  or  to  hold  them  nearly  together.  If, 
after  the  parts  are  approximated,  they  are  kept  antiseptically  clean, 
the  bones  will  kindly  unite  and  the  palate  will  be  restored,  so  that  its 
full  function  will  be  performed.  Separation  of  the  bones  is  attended 
with  little  hemorrhage,  and  the  parts  do  not  usually  cause  more  incon- 
venience to  the  patient  than  the  ordinary  operation  of  lifting  the  hard 
palate  according  to  the  practice  of  Fergusson. 

"  The  germs  of  the  teeth  are  sometimes  disturbed,  for  I  have  found 
later,  when  they  are  erupted,  that  certain  teeth  are  imperfectly  formed. 
This  applies  only  to  the  molars  of  the  temporary  set,  but  it  is  not 
unlikely  that  the  germs  of  the  permanent  teeth  may  also  be  disturbed 
and  the  teeth  made  imperfect  by  this  procedure.  The  palate,  too, 
may  be  contracted  to  an  abnormal  extent ;  and  yet  it  is  a  well-known 
fact  that  the  alveolar  process  develops  with  the  eruption  of  the  teeth, 
and  experience  has  convinced  me  that  in  mouths  thus  treated  the  teeth 
of  the  upper  antagonize  in  a  normal  way  with  those  of  the  lower  jaw. 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE   SYSTEM.        1 79 

If,  however,  the  upper  superior  arch  should  be  abnormally  contracted, 
and  when  the  teeth  erupt  fail  properly  to  antagonize  with  their  fel- 
lows of  the  lower  jaw,  means  well  known  to  the  modern  dentist 
may  be  employed  by  which  the  arch  can  be  expanded  and  the  slight 
abnormality  removed. 

"  After  the  approximation  of  the  edges  in  the  manner  described  the 
parts  should  be  thoroughly  dried,  the  edges  of  the  wound  carefully 
examined,  and,  if  need  be,  some  fine  sutures  inserted  here  and  there  to 
ensure  perfect  coaptation  of  the  parts." 

Tumors  of  the  palate  are  not  common.  Sarcoma  has  been 
observed  in  a  few  instances.  The  tumor  is  likely  to  be  mistaken  for 
an  abscess,  and  is  readily  lanced  by  the  unwary.  Epithelioma  rarely 
occurs  as  a  primary  affection,  but  may  extend  to  the  palate  from  the 
gums  or  tonsils.  Fibrous  growths  resembling  epulis  are  sometimes 
found  upon  the   hard  palate  and  require  removal. 

Syphilis. — The  manifestations  of  syphilis  as  found  in  the  palate  are 
the  following  : 

{a)  Mucous  patches,  oval  or  circular  in  shape,  raised  above  the  sur- 
rounding surface,  pale  blue  in  color  and  covered  with  moisture. 

(J?)  Perforating  ulcers  extending  through  the  hard  or  soft  palate  may 
always  be  regarded  as  syphilitic,  except  when  the  result  of  traumatism. 

(r)  Gummata  occur  as  firm,  sharply-defined  swellings  showing 
a  tendency  to  soften.  These  must  be  distinguished  from  abscess  of 
the  palate.  An  abscess  arises  near  the  alveolus,  and  usually  near  the 
incisor  teeth,  which  are  painful  and  may  be  loosened.  This  distribution 
is  very  important  in  view  of  treatment,  for  an  incision  is  needed  in  the 
case  of  abscess  to  prevent  necrosis  of  the  palate,  but  in  the  case  of 
syphilis  it  is  just  what  is  likely  to  cause  necrosis. 

{d)  A  serpiginous  syphilitic  ulcer  begins  behind  the  last  molar  tooth 
and  spreads  upward  over  the  palate,  healing  by  one  edge  and  leaving  a 
hard,  depressed  scar. 

(r)  Extensive  ulcerations  extending  over  palate,  tonsils,  and  pharynx, 
covered  with  foul  gray  sloughs  and  producing  great  destruction  of 
tissue,  are  syphilitic,  and  must  not  be  confounded  with  diphtheria  or 
malignant  scarlatina,  the  latter  of  which  runs  a  rapid  course. 

(/)  A  narrow,  highly-arched  palate  is  one  of  the  effects  of  inherited 
syphilis  (Gould). 

The   Mouth. 

In  examining  the  mouth  a  good  light  is  necessary.  The  inner  sur- 
faces of  the  cheeks  may  show  mucous  patches  or  the  ulceration  of 
syphilis.     Epithelioma  is  usually  an  extension  from  the  tongue. 

Salivary  calculus  is  felt  as  a  hard,  even  tumor,  tender  to  the 
touch,  and  between  the  sides  of  the  tongue  and  the  jaw.  It  may  pro- 
duce but  little  inconvenience,  such  as  stiffness  of  the  jaw  and  swelling 
of  the  submaxillary  gland,  but  at  times  the  inflammatory  symptoms  are 
marked  and  cause  swelling  of  a  great  part  of  the  mouth.  One  finger 
in  the  mouth  and  another  under  the  chin  will  readily  detect  the  stone, 
or  it  can  be  sounded  by  passing  a  probe  down  the  duct. 

Trcatmetit. — Make  a  free  incision  in  the  mucous  membrane  and 
remove  the  calculus,  taking  care  not  to  break  it,  as  it  is  difficult  to  get 


l80  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

rid  of  a  number  of  fragments.  The  stones  vary  in  size  from  that  of  a 
pea  to  that  of  a  pigeon's  egg. 

Ranula  is  a  name  given  to  a  cyst  beneath  the  tongue  on  one  or 
other  side  of  the  frenum.  It  is  generally  of  a  bluish  color  and  contain.s 
a  clear  mucus.  It  is  painless,  and  only  causes  trouble  by  its  bulk.  As 
a  rule  the  cyst-wall  is  thin  and  semi-transparent,  but  its  character  is 
subject  to  considerable  variation.  The  cause  of  ranula  has  been  much 
discussed,  but  it  is  generally  agreed  that  it  is  obstruction  and  dilatation 
of  one  of  the  mucous  follicles. 

Treatment. — The  old  method  of  treating  these  cysts  was  by  passing 
a  seton  through  them,  and  some  surgeons  still  adhere  to  this  plan.  It 
is  better  to  cut  a  piece  out  of  the  cyst-wall  by  means  of  scissors,  and 
then  destroy  the  remainder  of  the  cyst  by  the  application  of  solid  nitrate 
of  silver,  or  the  edges  of  the  incision  in  the  cyst-wall  can  be  held  back 
by  stitches. 

The  Tongue. 

Malformations. — The  malformations  of  the  tongue  are  three  in 
number — viz.  tongue-tie,  hypertrophy  of  the  tongue  or  macroglossia, 
and  atrophy. 

Tongue-tie  is  very  easily  recognized.  The  child  is  unable  to  pro- 
trude the  tongue  beyond  the  gums,  and  there  may  be  difficulty  in 
sucking.  If  allowed  to  go  untreated,  articulation  is  affected.  The  con- 
dition depends  upon  a  shortness  of  the  fraenum  linguae.  All  the  treat- 
ment necessary  is  division  of  this  band.  Place  the  child  on  its  back  on 
the  nurse's  lap  with  the  head  toward  you,  place  two  fingers  beneath  the 
tongue,  and  divide  the  frenum  with  scissors,  taking  care  to  point  the 
instrument  toward  the  floor  of  the  mouth  in  order  to  avoid  the  ranine 
artery.  A  small  nick  in  the  membrane  is  sufficient,  after  which  the 
division  is  completed  by  tearing  with  the  fingers. 

Hypertrophy  of  the  Tongue  (Macroglossia). — This  is  a  congenital 
disease,  and  many  of  the  subjects  of  it  are  also  epileptics.  The  tongue 
is  large  to  begin  with,  and  its  growth  is  greatly  increased  by  repeated 
attacks  of  glossitis.  As  the  organ  enlarges  it  produces  great  dis- 
comfort and  becomes  a  hideous  deformity.  Gradually  and  slowly 
enlarging,  the  tongue  passes  beyond  the  cavity  of  the  mouth,  distort- 
ing the  teeth  by  its  pressure  and  changing  the  shape  of  the  jaws. 
Cases  have  been  reported  in  which  the  tongue  protruded  over  the  chin 
and  down  to  the  sternum.  Saliv^a  constantly  dribbles  from  the  mouth. 
Speech  is  indistinct,  and  the  tongue  is  hard,  purplish  in  color,  and 
occasionally  ulcerated. 

Treatment. — Some  cases  have  been  reported  in  which  the  use  of 
styptics,  such  as  sulphate  of  copper  (Syme),  has  been  successful,  com- 
bined with  pressure.  The  most  satisfactory  results,  however,  will  be 
obtained  by  the  removal  of  a  V-shaped  portion  of  the  organ.  This  is 
best  done  by  passing  stout  threads  through  the  end  of  the  tongue, 
drawing  it  well  forward,  and  then  by  knife,  galvano-cautery,  or  ecraseur 
removing  the  necessary  amount  of  tissue. 

Atrophy  of  the  tongue  is  always  confined  to  one  side,  and  is  not 
congenital.  It  is  found  in  connection  with  brain-disease  or  injury, 
especially  when  the  hypoglossal  nerve  is  involved. 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE   SYSTEM.        l8l 

Injuries  of  the  Tongue. — Common  injuries  of  the  tongue  are 
wounds,  caused  by  accidental  biting  of  the  organ,  due  to  falls,  incision 
by  sharp  instruments,  the  bite  of  insects,  and  scalds.  The  treatment  can 
generally  be  left  to  nature.  Wounds,  when  extensive,  should  be  treated 
by  suture,  care  being  taken  to  use  deep  sutures.  If  healing  should  be 
retarded  by  an  acrid  condition  of  the  saliva,  this  can  be  remedied  by  the 
use  of  alkaline  washes. 

Diseases  of  the  Tongue. — Inflammation  of  the  tongne  (glos- 
sitis) is  usually  the  result  of  some  local  irritation  or  injury,  but  apart 
from  any  local  cause  an  idiopathic  acute  glossitis  is  recognized,  which 
is  by  some  regarded  as  catarrhal,  by  others  as  a  parenchymatous 
inflammation.  It  is  a  rare  affection,  and  is  almost  confined  to  adult 
males.  The  first  indication  of  the  disease  is  tenderness  of  the  tongue 
felt  in  the  mastication  of  food  or  in  the  drinking  of  hot  liquids.  Swell- 
ing progresses  rapidly,  until  the  organ  fills  the  mouth  and  protrudes 
beyond  the  lips.  Saliva  is  secreted  in  excessive  quantities  and  dribbles 
from  the  mouth.  At  first  dry  and  shining,  the  tongue  becomes  ulcer- 
ated, and  in  rare  cases  deep  suppuration  takes  place.  Difficulty  of 
breathing  may  become  so  urgent  a  symptom  as  to  require  tracheot- 
omy for  its  relief  The  disease  generally  runs  a  course  of  five  or  six 
days,  and  then  subsides. 

The  ordinary  treatment  consists  in  giving  a  saline  cathartic  and 
employing  a  wash  of  chlorate  of  potash  or  a  solution  of  Seller's  anti- 
septic tablets.  When  the  symptoms  are  urgent  surgical  interference  is 
called  for.  An  incision  along  each  side  of  the  raphe  near  the  base  of 
the  tongue,  deep  enough  to  cause  free  bleeding,  will  be  promptly  fol- 
lowed by  relief  of  swelling  and  subsidence  of  the  inflammatory  symp- 
toms.    If  suffocation  appears  to  be  imminent,  tracheotomy  is  required. 

Tuberculosis  of  the  Tongne. — This  disease  is  usually  secondary  to 
a  manifestation  in  some  other  organ,  as  the  lungs  or  the  larynx,  and  is 
then  recognized  without  great  difficulty.  When  it  occurs  as  a  primary 
affection  its  diagnosis  is  difficult,  and  more  than  one  tongue  has  been 
excised  with  the  idea  that  it  was  the  seat  of  cancer.  The  disease  appears 
as  fissures  on  the  sides  and  tip  of  the  tongue,  but  more  frequently  as 
ulcers,  singly  or  in  numbers.  The  ulcer  is  frequently  stellate  in  shape, 
and  may  attain  considerable  depth.  The  edges  are  sharply  cut,  but 
there  is  no  induration  around  its  base. 

The  diagnosis  can  sometimes  be  settled  by  finding  tubercle  bacilli  in 
scrapings  from  the  ulcer.  It  is  often  excessively  painful,  and  runs  a 
course  varying  from  a  few  months  to  two  years. 

Syphilis  of  the  Tongue. — Of  all  diseases  of  the  tongue,  this  is 
probably  most  common.  Fissures  are  the  most  common  manifestation 
of  the  disease,  and  are  very  suggestive  of  the  tertiary  stage.  They  may 
be  single  or  multiple.  They  are  irritable  and  sensitive  to  touch,  but  the 
surrounding  tissue  is  not  inflamed.  When  situated  on  the  side  of  the 
tongue  they  indicate  the  secondary  stage,  and  are  best  treated  with 
mercury,  while  the  tertiary  variety  yields  more  readily  to  iodid  of 
potassium. 

Ulceration  is  superficial  in  the  secondary  stage  and  appears  above 
the  edges  of  the  tongue.  When  deep  and  covered  with  a  dirty  grayish 
secretion,  they  are  tertiary  and  follow  the  breaking  down  of  gummata. 


1 82  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

They  commonly  occur  in  the  dorsum  of  the  tongue.  Their  edges  are 
sharply  defined  and  their  bases  indurated. 

Chancre  on  the  tongue  is  exceedingly  rare.  It  is  a  single  ulcer 
near  the  tip  of  the  tongue.  Its  edges  and  base  are  indurated,  and  the 
glands  beneath  the  jaw  are  swollen  and  hard. 

Carcinoma  of  the  Tongue. — Perhaps  there  is  no  disease  which  the 
general  practitioner  so  reluctantly  decides  upon  as  cancer  of  the  tongue. 
An  ulcer  of  the  tongue  may  continue  for  many  months,  apparently 
neither  healing  nor  spreading,  giving  little  or  no  pain  and  producing 
but  slight  inconvenience.  To  pronounce  such  a  case  cancer  would  be 
to  strike  terror  into  the  hearts  of  the  patient  and  his  friends,  and  the 
fear  of  being  in  error  after  all  deters  the  practitioner  from  making  such 
a  diagnosis.  These,  however,  are  the  very  cases  suitable  for  operation, 
the  ones  in  which  an  early  diagnosis  is  of  value.  Another  common 
error  is  to  treat  the  ulceration  by  the  application  of  nitrate  of  silver 
and  other  caustics.  This  can  do  no  possible  good,  and  if  frequently 
repeated  the  irritation  may  cause  a  cancerous  development  in  an  ulcer 
which  might  remain  benign. 

In  no  situation  is  carcinoma  more  common,  except  it  be  the  lower 
lip ;  the  form  it  assumes  is  epithelioma.  Scirrhus  is  exceedingly  rare. 
Men  suffer  more  frequently  than  women,  the  ratio  being  more  than  five 
to  one.  The  earliest  sign  of  the  disease  is  a  crack  or  ulcer  more  or  less 
hard,  having  a  puckered  appearance  and  causing  a  characteristic  pain 
from  the  first.  Sometimes,  instead  of  a  single  ulcer,  there  are  several 
small  nodules,  which  sooner  or  later  coalesce  and  form  a  foul  and 
ragged  sore  covered  with  granulations. 

In  the  diagnosis  of  this  disease  the  following  points  require  attention  : 

1.  Age. — There  is  one  decade  which  claims  the  majority  of  cases  of 
cancer :  it  is  from  forty-five  to  fifty-five.  An  ulcer  on  the  tongue  of  a 
person  over  forty  years  of  age  should  excite  suspicion  and  will  bear 
watching.     Should  it  refuse  to  heal,  it  ought  to  be  excised. 

2.  Habits  of  the  Patient. — While  cancer  of  the  tongue  may  arise 
without  any  apparent  cause,  there  is  no  doubt  that  local  irritation  plays 
a  part  in  its  causation.  Smoking,  a  badly-adjusted  dental  plate,  a  sharp 
tooth,  sharp,  ragged,  irregular  roots,  or  local  injury  may  cause  ulcera- 
tion which  later  takes  on  the  characteristics  of  cancer. 

3.  Situation  of  the  Uleer. — The  sides  of  the  anterior  half  of  the 
tongue  and  the  under  side  of  the  tip  are  the  favorable  starting  points. 
A  sharp  or  abnormally  placed  tooth  by  its  constant  irritation  may 
determine  the  position  of  the  ulcer. 

Cancer  may  follow  as  a  sequel  of  two  other  diseases — viz.  syphilis 
and  leukoma. 

4.  Microscopic  examination  of  a  small  portion  of  the  ulcerated  tissue 
should  be  resorted  to  in  case  of  doubt. 

5.  Progress  of  the  Disease. — From  the  slight  ulceration  appearing  on 
the  side  or  under  the  tip  of  the  tongue  infiltration  passes  with  more  or 
less  rapidity  to  the  floor  of  the  mouth,  to  the  gums,  the  tonsils,  and 
pillars  of  the  fauces.  Glandular  involvement  is  first  found  about  the 
submaxillary  region  or  in  the  glands  about  the  angle  of  the  jaw.  The 
tongue  loses  its  power  of  motion  to  a  considerable  extent,  and  cannot 
be  protruded.     Salivation  is  profuse  and  distressing;  the  fetor  becomes 


INJURIES  AXD   DISEASES   OF   THE   DIGESTIVE   SYSTEM        1 83 

offensive,  and  deglutition  difficult.  The  tissues  break  down,  and,  should 
the  large  vessels  suffer,  death  by  hemorrhage  may  occur  suddenly. 
Constant  pain,  starvation,  loss  of  sleep,  combine  to  wear  out  the  unfor- 
tunate patient,  till  at  the  end  of  a  period  varying  from  one  to  two  years 
the  long  agony  is  ended  by  merciful  death. 

Carcinoma  of  the  tongue  must  be  distinguished  from  the  following : 
{a)  Simple  Ulcer. — Simple  ulceration  may  occur  at  any  age  or  on 
any  part  of  the  tongue,  and  is  generally  the  result  of  a  local  irritant. 
The  teeth  should  be  carefully  examined  for  sharp  projections.  Trau- 
matisms and  glossitis  must  be  taken  into  account.  In  simple  ulcer 
there  is  little  or  no  hardness  about  the  base,  while  in  carcinoma  the 
surrounding  parts  are  deeply  infiltrated.  After  removal  of  the  cause  a 
simple  ulcer  tends  to  heal,  while  carcinoma  shows  no  such  tendency. 
In  a  person  over  forty  a  chronic  ulcer  of  the  tongue  should  be  set 
down  as  cancerous  and  freely  removed. 

{b)  Syphilitic  Ulcer. — There  is  usually  a  history  of  syphilis  in  other 
parts  of  the  body,  and  an  initial  sore.  The  position  of  the  ulcer  is  on 
the  dorsum  of  the  tongue,  and  not  on  the  sides  or  under  the  tip,  as  in 
cancer.  The  posterior  cervical  glands  are  enlarged  in  syphilis,  while 
the  submaxillar}'  are  affected  in  cancer. 

Differential  Diagnosis  detzuceti  Syphilitic  and  Carcinomatous  Ulcers 

of  the  Tongne. 
Syphu-itic.  Carcinomatous. 

Age. — Any  time  after  puberty.  Forty-five,   and  especially  between   forty-five 

and  fifty-five. 
History. — Previous  manifestations  of  syphilis.     Probably  none.     Perhaps  irritation  as  from  a 

sharp  tooth  or  short  pipe. 
Situation. — Dorsum  or  sides.  Sides  or  under  tip. 

Character. — Edges  well  defined,  but  not  in-     Edges   everted,  hard    surface    covered    with 

durated.  characteristic  granulations. 

Pain. — Slight  soreness.  Burning,  darting,  or  cutting. 

Glands. — Posterior  cervical  enlarged.  Submaxillary  and  sublingual  are  affected. 

Effect    of    Treatment. — Responds    to    anti-     No  tendency  to  heal  under  any  treatment. 

syphilitics. 

{c)  Tuberctilons  Ulcer. — When  there  are  other  manifestations  of 
tuberculosis,  such  as  phthisis,  there  is  no  difficulty,  but  when  the  ulcer 
occurs  primarily  on  the  tongue  the  question  is  very  obscure.  The  ulcer 
should  be  scraped  with  a  knife,  and  the  material  removed  examined  for 
tubercle  bacilli.     This  form  of  ulcer  is  rare. 

Treatment. — One  method  of  treatment,  and  one  only,  is  of  any  avail, 
and  that  is  complete  removal  of  the  disease  by  surgical  operation. 
There  is  always  a  temptation  to  treat  a  cancerous  ulcer  by  means  of 
caustics,  but  this  is  a  dangerous  procedure  and  should  never  be  fol- 
lowed. Two  points  should  never  be  lost  sight  of — viz.  early  diagnosis 
and  complete  removal. 

Removal  of  a  Portion  of  the  Tongne. — In  cases  which  have  been 
diagnosticated  at  an  early  period  of  the  disease,  when  a  small  ulcer 
exists  on  one  side  or  under  the  tip  of  the  tongue,  without  any  glandular 
involvement,  the  whole  of  the  cancerous  portion  can  be  removed  by 
taking  away  only  a  part  of  the  tongue.  The  best  instrument  for  this 
operation    is  the    knife   or  scissors,  although   the   wire    and    galvanic 


1 84  SURGICAL   DIAGXOSrS  AND    TREATMENT. 

ccrascur  are  often  employed.  The  mouth  bcin^  licld  open  with  a 
suitable  gag,  two  strong  sutures  are  passed  through  the  tip  of  the 
tongue,  one  on  either  side  of  the  raphe,  and  the  organ  drawn  well  out 
of  the  mouth.  With  the  scissors  the  tongue  is  split  down  the  middle 
and  separated  from  the  floor  of  the  mouth.  If  the  ecraseur  is  employed, 
two  stout  needles  are  passed  through  the  detached  half  of  the  tongue, 
and  the  wide  loop  passed  round  behind  the  needles,  or  the  division  can 
be  completed  with  scissors. 

Removal  of  the  Whole  Tongue. — Strange  as  it  may  appear,  total 
removal  of  the  tongue  does  not  necessarily  interfere  with  speech,  taste, 
or  deglutition.  Mr.  Syme  operated  upon  a  case,  dividing  the  lower  jaw 
at  its  symphysis  and  removing  the  whole  tongue.  The  patient  not  only 
recov^ered  from  the  disease,  but  his  speech  was  wonderfully  clear  and 
distinct,  and  he  could  sing  without  difficulty.  Taste,  though  impaired, 
enabled  him  to  detect  bitter  from  sweet,  grouse  from  partridge,  good 
beer  from  bad.  He  also  swallowed  with  ease  when  the  food  was 
liquid  or  finely  divided. 

Two  special  dangers  are  recognized  in  total  removal  of  the  tongue : 

1.  Hemorrhage. — To  guard  against  this  the  ecraseur  has  been  a 
favorite  instrument,  but  a  serious  objection  to  its  use  is  the  extensive 
sloughing  which  always  results.  A  very  simple  method  of  temporarily 
controlling  hemorrhage  from  the  tongue  was  devised  by  Heath.  He 
passed  the  fore  finger  well  down  to  the  epiglottis,  and  hooked  forward 
the  OS  hyoides,  dragging  it  upward  as  far  as  possible  toward  the  sym- 
physis of  the  lower  jaw.  In  this  way  the  two  lingual  arteries  are 
stretched  to  such  a  degree  that  circulation  in  them  ceases,  rendering 
the  anterior  part  of  the  tongue  almost  bloodless.  In  some  operations 
preliminary  ligation  of  the  lingual  and  facial  arteries  effectually  controls 
hemorrhage. 

2.  Sepsis  from  the  mouth  and  throat,  leading  to  pneumonia  and  gen- 
eral septicemia.  To  guard  against  this  danger  operations  have  been 
devised  by  which  the  incision  is  made  beneath  the  jaw,  or  a  preliminary 
tracheotomy  is  made  and  a  tube  inserted  through  which  the  patient 
breathes  during  the  whole  period  of  healing. 

Of  a  large  number  of  different  operations  which  have  been  devised, 
two  seem  to  be  in  general  favor — Kocher's  and  Whitehead's. 

I.  Kochers  Operation. — The  attractive  part  of  this  operation  is  that 
it  aims  at  asepsis  throughout. 

First  Step. — Tracheotomy  is  performed  as  a  preliminary,  and  an 
accurately  fitting  tube  inserted. 

Second  Step. — An  incision  is  made  beginning  a  little  below  the 
lobule  of  the  ear,  along  the  anterior  border  of  the  sterno-mastoid 
to  the  middle  of  that  muscle,  then  forward  to  the  hyoid  bone,  along  the 
upper  edge  of  the  greater  cornu,  and  upward  along  the  anterior  belly 
of  the  digastric  muscle  to  the  chin  (Fig.  89).  This  forms  a  flap  which 
is  dissected  off  and  turned  up  over  the  cheek.  The  facial  artery  and 
veins  are  ligated,  and  the  lingual  artery  tied  in  Lesser's  triangle.  All 
the  glands  of  the  submaxillary  fossa  are  removed,  also  the  submaxil- 
lary and  sublingual  glands.  If  only  one  side  of  the  tongue  is  to  be 
removed,  this  is  sufficient,  but  when  our  purpose  is  to  remove  the  whole 
organ  the  opposite  lingual  artery  must  be  ligated  in  a  special  incision. 


INJURIES  AND   DISEASES    OE   THE   DIGESTIVE   SYSTEM.        1 85 


Fio.  89. — Kocher's  incision  for 
removal  of  the  tongue  (Esmarch 
and  Kowalzig). 


Third  Step. — A  sponge  large  enough  to  prev^ent  blood  flowing  into 
the  throat  is  attached  to  a  strong  silk  thread  and  pushed  well  down 
into  the  pharynx.  By  means  of  scissors  the  mucous  membrane  along 
the  jaw,  and  also  the  mylo-hyoid  muscle,  are  divided.  Through  this 
opening  the  tongue  is  drawn  out  below^  the  jaw,  and,  having  been 
freed  beyond  the  utmost  limits  of  the  dis- 
ease, it  is  divided  with  scissors. 

Fourtli  Step. — The  cut  surfaces  are  now 
thoroughly  rubbed  with  crystals  of  per- 
manganate of  potash.  This  forms  a  hard, 
firm  incrustation,  which  not  only  serves  to 
arrest  oozing  of  blood,  but  is  an  excellent 
antiseptic.  It  is  better  than  packing  the 
mouth  and  fauces  with  iodoform,  which 
always  adds  to  the  distress  and  suffering 
of  the  patient,  increasing  the  tendency  to 
vomit. 

The  after-treatment  consists  in  keeping 
the  tracheal  tube  thoroughly  clear  and 
washing  the  mouth  frequently  with  such 
antiseptic  fluids   as   peroxid  of  hydrogen, 

boracic  acid,  and  Condy's  fluid.  For  the  first  two  or  three  days  ali- 
mentation must  be  by  the  rectum  entirely.  After  that  the  food  can  be 
introduced  into  the  stomach  by  a  tube  passed  into  the  throat  well 
beyond  the  raw  surfaces. 

2.  WhitcJicacV s  Operation. — The  patient  is  placed  in  a  good  light,  a 
needle  introduced,  and  the  tongue  drawn  well  out  of  the  mouth  by  a 
strong  silk  ligature  through  its  tip.  The  dissection  is  made  with  scis- 
sors, beginning  at  the  frenum,  and  by  short  rapid  snips  dividing  the 
organ  from  its  attachment  and  giving  the  disease  a  wide  berth,  until 
not  only  the  cancerous  portion,  but  a  good  part  of  the  apparently 
healthy  tissue,  is  removed.  As  soon  as  the  lingual  arteries  are  cut 
they  should  be  seized  with  hemostatic  forceps  and  ligated.  Should 
hemorrhage  prove  troublesome,  a  strong  silk  ligature  should  be  passed 
through  the  remains  of  the  glosso-epiglottidean  fold  and  left  in  position 
twenty-four  hours. 

Tumors  of  the  Tongue. — Tumors  of  the  tongue  are  not  common, 
but  the  following  varieties  are  occasionally  met  with  :  viz.  papillomata, 
nevi,  fatty  tumors,  and  erectile  tumors. 

PapilloDiata,  or  zvarty  tumors,  are  found  on  the  dorsum  of  the 
tongue  or  on  the  sides  well  toward  the  root.  They  resemble  ordinary 
seed-warts,  and  are  of  little  consequence  except  when  they  are  very 
vascular. 

The  treatment  consists  in  drying  the  part  and  applying  London 
paste  (Garretson),  or  the  growth  may  be  transfixed  w^ith  a  needle  and 
ligated.     When  small  the  growth  can  be  snipped  off  with  scissors. 

Nevi  are  met  with  about  the  tip  of  the  tongue,  and  are  treated  on 
the  general  principles  which  govern  the  removal  of  these  growths  else- 
where. If  ligature  is  employed,  it  must  be  placed  in  healthy  tissue  well 
away  from  the  growth  and  tightly  tied.  The  ecraseur,  if  employed, 
must  take  away  ample  material,  and  is  best  suited  for  cases  in  which 


l86  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

the  growth  is  large  and  cliffuse.  Simple  cases  may  be  treated  with 
puncture  of  thermo-cautery  needles  or  the  application  of  nitric  acid. 

Fatty  tumors  are  rare  in  this  locality,  and  need  no  special  mention. 

Erectile  Tumors. — Garretson  reports  five  cases.  The  most  important 
of  these  occurred  in  a  child  nine  months  of  age.  The  tumor  was  con- 
genital and  occupied  the  anterior  half  of  the  tongue.  It  was  of  a  dark- 
red  or  purple  color,  and  enlarged  to  a  marked  degree  every  time  the 
infant  cried.  Manipulation,  on  the  other  hand,  almost  caused  the  tumor 
to  disappear.     It  was  successfully  removed  by  operation. 

Cartilaginous  tumors  have  been  found  on  the  tongue,  but  they  are 
exceedingly  rare.     Their  treatment  is  removal. 

The  Jaws  and  Gums. 

Deformities. — Cleft-palate,  the  most  common  of  all  deformities 
of  the  jaw,  has  been  already  considered.  Other  deformities  are  rare, 
but  we  must  recognize  (a)  failure  of  union  between  the  two  halves  of 
the  lower  jaw  ;  (//>)  arrest  of  development  on  one  side  of  the  lower  jaw ; 
ic)  congenital  dislocation. 

In  cases  of  marked  hypertrophy  of  the  tongue  constant  pressure 
may  produce  displacement  of  the  teeth  and  even  dislocation  of  the  jaw. 
Burns  and  scalds,  followed  by  extensive  cicatricial  contraction,  may 
draw  the  chin  or  lower  lip  down  to  the  sternum.  Sucking  the  thumb 
may  cause  deformity  of  the  jaw. 

In  the  diagnosis  of  diseases  of  the  jaw  it  is  convenient  to  divide 
them  into  two  classes — acute  and  cJironic. 

The  acute  forms  are  inflammatory,  and  the  most  common  are 
abscess  of  the  gums  or  alveoli  and  periostitis. 

When  Burns  characterized  toothache  as  the  "  hell  of  all  diseases," 
he  no  doubt  drew  his  inspiration  from  an  attack  of  periodontitis  ending 
in  abscess,  vulgarly  called  "  gum-boil."  The  cause  of  this  common 
affection  is  suppurating  pulp.  The  diagnosis  is  easy.  There  is  a  his- 
tory of  the  characteristic  pain  of  toothache ;  tenderness  and  swelling 
are  felt  by  passing  the  finger  along  the  gums.  The  tooth  is  elongated 
and  tender  on  tapping.  The  face  on  the  affected  side  is  swollen,  and 
finally  a  collection  of  pus  takes  place.  If  the  suppuration  is  near  the 
surface,  it  readily  finds  exit  or  can  be  released  by  simple  puncture ;  it 
may  find  its  way  through  the  skin  and  open  about  the  lower  margin 
of  the  jaw.     Necrosis  in  that  case  is  a  common  result. 

Treatment. — In  the  early  stage  the  gum  may  be  painted  with  iodin. 
Fomentations  by  means  of  a  small  compress  of  lint  or  absorbent  cot- 
ton dipped  in  hot  water  and  repeatedly  applied  relieve  the  pain  and 
hasten  suppuration.  When  the  pus  is  near  the  surface  of  the  gum, 
simple  puncture  will  suffice ;  when  deeper  a  free  opening  should  be 
made.  The  tooth  causing  the  trouble  should  receive  the  attentions  of 
a  dentist    and  be  either  saved  or  extracted. 

Periostitis  or  osteo-periostitis  is  to  be  diagnosticated  when  the 
inflammation  spreads  over  a  considerable  portion  of  jaw,  attended  with 
high  fever,  the  loosening  of  several  teeth,  and  excessive  tenderness. 

Chronic  Affections  of  the  Jaw. — A  chronic  affection  of  the 
jaw  must  be  necrosis,  periostitis,  or  a  tumor. 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE   SYSTEM.        1 8/ 

Necrosis  results  from  tuberculosis,  syphilis,  a  decayed  tooth,  or  a 
traumatism.  It  may  follow  one  of  the  zymotic  diseases,  and  it  is 
common  among  those  who  have  to  breathe  the  fumes  of  phosphorus. 
It  is  always  preceded  by  severe  pain  and  inflammation.  Suppuration 
takes  place,  and  one  or  more  sinuses  result.  Through  one  other  of 
these  openings  a  probe  can  be  made  to  touch  the  necrosed  bone.  If 
only  one  sinus  exists  and  the  probe  is  felt  to  touch  a  smooth  surface,  it 
is  likely  to  prove  the  root  of  the  tooth.  It  must  be  remembered  that 
here,  as  elsewhere,  the  external  opening  may  be  no  indication  of  the 
position  of  the  diseased  portion  of  bone.  The  opening  may  be  on  the 
face,  the  neck,  or  even  in  the  nose. 

Treatment. — While  the  treatment  is  the  same  as  for  necrosis  in  other 
parts  of  the  body,  one  or  two  special  points  must  be  kept  in  mind. 
The  sequestrum  should  be  removed,  if  possible,  from  the  inside  of  the 
mouth,  and  no  attempt  at  detachment  should  be  made  until  the  seques- 
trum is  perfectly  loose ;  otherwise  the  soft  parts,  especially  the  vessels, 
may  be   injured. 

Chronic  periostitis  is,  as  a  rule,  syphilitic.  The  common  situations 
are  the  outer  side  of  the  lower  jaw  and  the  hard  palate.  There  are 
generally  other  indications  of  specific  disease,  and,  should  the  surgeon 
be  still  in  doubt,  he  can  settle  the  point  by  putting  the  patient  upon 
antisyphilitic  treatment. 

Phosphorus  Necrosis. — With  better  attention  to  the  sanitary  condi- 
tions of  factories  phosphorus-poisoning  is  much  less  common  than 
formerly.  The  disease  is  usually  extensive  and  its  course  rapid,  so 
that  a  patient  may  apply  for  advice  whose  jaw  is  necrosed  to  a  con- 
siderable extent  without  his  being  aware  of  it.  Diagnosis  will  depend 
upon  the  history  and  the  ordinary  signs  of  necrosis. 

Tumors  of  the  Jaws. — Epulis  ilTii,  upon,  and  doXa,  gums)  is  a  mor- 
bid growth  improperly  named.  Instead  of  being  connected  with  the 
gums,  it  is  a  tumor  growing  from  the  periosteum  of  the  alveolar  process 
and  sockets  of  the  teeth.  When  first  recognized  it  appears  to  be  making 
its  way  from  about  the  neck  of  some  particular  tooth  (Garretson). 

Simple,  Benign  Epulis. — The  most  common  form  of  epulis  is  that 
which  is  connected  with  the  pulp  of  a  tooth,  the  epulo-pulp-fungoid 
tumor.  It  originates  in  the  exposed  tooth-pulp,  and  by  gradual 
increase  covers  the  gum  adjacent  to  the  affected  tooth.  After  a  time 
it  ulcerates  and  discharges  a  sero-purulent  fluid,  or  it  may  undergo 
ossification.  Another  variety  of  epulis  is  the  erectile  or  nevoid.  Both 
of  the  foregoing  are  simple  and  benign  in  character. 

Malignant  Epulis. — Malignant  epulis  begins  like  the  benign  forms, 
but  its  rapid  growth,  its  vascular  character,  its  purplish  color,  and  its 
tendency  to  form  a  fungous  mass  protruding  between  the  teeth  and 
bleeding  on  the  slightest  provocation  reveal  its  serious  nature  and 
demand  its  radical   removal. 

Treatment. — The  benign  forms  require  the  removal  of  the  involved 
tooth  and  the  portion  of  the  alveolar  process  which  forms  its  socket. 
The  malignant  epulides  must  be  dealt  with  as  cancerous  tumors.  Not 
only  the  socket,  but  a  portion  of  the  jaw,  must  be  removed.  The 
doomed  section  of  the  maxilla  should  be  sawn  through  by  two  vertical 
cuts,  and  the  intervening  portion  removed  by  strong  forceps. 


1 88  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

In  the  diagnosis  of  tumors  of  the  jaws  the  first  question  to  settle  is 
whether  a  gi\en  tumor  is  cystic  or  sohd.  Cystic  tumors  are  not  un- 
common in  this  situation.  A  cystic  tumor  is  smooth,  and  rises  above 
the  surrounding  bone  by  gradual  elevation.  Fluctuation  may  be 
detected  in  tiie  growth,  or  the  bony  cyst- wall  may  crackle  like  an  egg- 
shell under  the  pressure  of  the  fingers.  When  these  conditions  are 
found,  examine  the  teeth  at  that  part  and  in  all  probability  you  will 
find  one  tooth  missing.  Or  it  may  be  that  the  deciduous  tooth  at  that 
point  has  never  been  cast  off.  These  tumors  are  liable  to  be  mistaken 
for  malignant  disease  of  the  bone,  but  the  surface  is  perfectly  smooth, 
the  patient  is  generally  )'oung,  and  the  growth  is  painless  ;  all  of  which 
argue  against  malignancy.  When  this  smooth  tumor  is  cut  down  upon, 
the  thin  bone  readily  gives  away  and  a  cavity  is  opened  up.  Explore 
this  cavity,  and  out  will  pop  a  tooth  which  lay  loose  in  a  thick 
mucilage-like  fluid  or  perhaps  turned  upside  down.  Even  when  crack- 
ling is  absent  the  smoothness  of  the  tumor  should  arouse  suspicion, 
and  this  will  be  confirmed  by  finding  that  one  of  the  permanent  teeth 
has  never  been  cut.  It  is  a  good  rule  never  to  remove  a  tumor  of  the 
jaw  without  first  cutting  into  it.  While  these  dentigerous  cysts  are 
mostly  confined  to  young  persons,  too  much  stress  must  not  be  laid 
upon  that  point.  In  a  case  upon  which  I  operated  a  short  time  ago 
the  tumor  was  smooth  and  apparently  as  hard  as  ivorj- ;  there  was  no 
crackling,  and  the  patient  was  fifty  years  of  age.  The  tumor  contained 
a  large  molar  tooth. 

The  cyst  can  be  reached  by  an  external  incision,  but  when  practi- 
cable an  opening  from  the  inside  of  the  mouth  will  prove  just  as  satis- 
factory, and  has  the  advantage  of  leaving  no  disfiguring  scar. 

Another  form  of  cystic  tumor  common  in  the  lower  jaw  is  irregular 
and  lobulated.  This  is  imdtilocitlar  cyst,  which  in  the  majority  of  cases 
is  a  cystic  degeneration  of  a  sarcoma  or  carcinoma.  Total  extirpation 
is  the  only  treatment. 

Solid  Tumors  of  the  Jaws. — These  are  naturally  classified  as 
benign  and  malignant. 

In  the  diagnosis  of  solid  tumors  of  the  jaw  begin  by  examining 
the  face,  mouth,  and  nose.  The  consistence  of  the  tumor  should  be 
felt  by  first  placing  the  fingers  outside  the  cheek  and  rolling  the  skin 
over  the  growth  ;  then  the  fingers  should  be  placed  in  the  mouth  and 
a  bimanual  examination  made.  Having  satisfied  yourself  of  the  con- 
sistency of  the  tumor,  pass  the  fingers  over  the  hard  palate  and  back- 
ward over  the  soft  palate  to  the  posterior  nares.  The  nostril  will 
require  careful  examination,  and  this  can  be  carried  out  by  throwing  a 
strong  light  into  it  and  testing  any  suspicious  growth  with  a  probe.  If 
in  this  examination  a  growth  is  found  attached  to  the  turbinated  bones,  it 
is  a  polypus.  A  tumor  in  the  antrum  will  also  show  itself  in  the  nostril, 
but  at  the  same  time  there  will  be  expansion  below  the  eyelid  and 
perhaps  protrusion  of  the  eyeball. 

The  non-malignant  tumors  are  the  following  : 

I.  Fibromata. — The  growth  of  these  tumors  is  slow,  and  they  are 
generally  painless.  They  start  from  the  periosteum,  and  especially 
from  the  periosteum  of  an  alveolus,  which  renders  these  growths  liable 
to  be  mistaken  for  epulis.     When  they  arise  from  the  periosteum  the 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE   SYSTEM.        1 89 

growth  is  smooth  or  lobulated,  firmly  attached  to  the  bone,  and  freely- 
movable  over  the  surrounding  parts.  When  the  endosteum  is  the 
starting-point  the  tumor  gradually  expands  the  jaw,  and  if  allowed  to 
grow  attains  an  enormous  size.  If  the  growth  is  in  the  upper  jaw,  the 
antrum  or  nasal  fossae  are  apt  to  be  encroached  upon.  We  recognize 
pressure  upon  the  antrum  by  observing  the  following  points :  The 
outer  wall  of  the  antrum  below  the  orbit  bulges  forward.  If  the  floor 
of  the  orbit  is  pressed  upon,  the  eyeball  protrudes.  Examination  by  the 
mouth  will  show  that  the  roof  of  the  mouth  is  flattened  or  depressed. 

2.  Enclwiidromata,  or  cartilaginous  tumors,  are  not  common.    They 
are  more  rapid  in  their  growth  than  fibromata,  are  much  harder,  and 


111 

Fig.  90. — Recurrent  ossifying  enchondroma  (Heath). 

are  more  nodular  (Fig.  90).  The  lower  jaw  and  the  antrum  are  favorite 
situations. 

3.  Ostconiata,  or  osseous  tumors,  are  still  more  rare.  They  are 
harder  even  than  the  cartilaginous  tumors,  and  may  take  the  form  of 
exostoses  or  may  present  the  appearance  of  a  general  thickening  of 
the  whole  bone. 

Treatjnent. — Fibromata,  enchondromata,  and  osteomata  should  all 
be  treated  by  thorough  removal  of  the  growths.  The  enchondromata 
are  apt  to  recur  after  removal. 

Malignant  tumors  are — 

I.  Carciiioinata. — Primary  cancer  of  the  jaw  is  rare.  The  majority 
of  cases  are  those  in  which  the  disease  spreads  from  the  nasal  mucous 
membrane  or  from  the  palate  (Fig.  91).  In  either  case  great  destruction 
of  tissue  may  take  place  without  any  marked  tumor  being  developed. 
A  probe  passed  through  a  small  external  opening  may  reveal  a  large 
cavity,  while  there  is  no  evidence  of  a  cancerous  mass  by  external 
appearances.  Three  characters  of  malignant  tumors  must  be  kept  in 
mind — viz.  rapid  growth,  destruction  of  bone,  and  fungation  into  the 


190 


SC-A'G/C.IL    1)/AGA'0S/S  AND    TREATMENT. 


inoutli.  Fibrous,  cartilaginous,  and  osseous  tumors  are  slow  in  grow- 
ing ;  thc\-  are  hard  to  the  touch,  they  do  not  affect  the  general  health, 
and  are  painless,  and,  except  when  they  exert  pressure  upon  neighbor- 
ing parts,  they  do  not  involve  the  surrounding  structures.  Carcinoma 
is  soft  and  has  a  tendency  to  fungate.  It  is  painful,  soon  telling  on  the 
general  health  of  the  patient,  and  involving  adjacent  structures,  espe- 
cially the  lymphatic  glands.  Fungation  is  strongly  characteristic  of 
cancer.  It  must  be  borne  in  mind,  however,  that  benign  tumors,  par- 
ticularly of  the  lower  jaw,  may  in  the  course  of  time  break  through  the 
skin  and  form  a  fungating  mass.      This,  however,  is  slow  of  growth, 


Fig.  91. — Epithelioma  of  the  left  malar  and  superior  maxillary  (Heath). 

as  was  also  the  tumor  which  gave  rise  to  it,  and  it  is  more  healthy  in 
appearance  than  a  cancerous  fungus. 

2.  Sarcomata. — The  round-celled  or  medullary  sarcoma  is  found 
most  frequently  in  the  upper  jaw,  and  bears  a  close  resemblance  to 
medullary  cancer.  Its  leading  characteristics  are  rapidity  of  growth, 
softness,  and  tendency  to  fungate.  In  the  majority  of  cases  the  disease 
begins  in  the  antrum.  As  the  tumor  increases  in  size  it  produces  symp- 
toms which  vary  according  to  the  direction  taken  by  the  growth.  The 
projecting  mass  may  show  on  the  cheek,  causing  closure  of  the  nasal 
duct,  producing  epiphora  and  edema  of  the  eyelids.  In  other  cases  the 
growth  takes  a  direction  inward,  and  forms  fungous  masses  in  the  nose 
or  mouth.  Sometimes  the  disease  starts  in  the  hard  palate,  the  alveolus, 
or  the  nose.  The  difficulty  here  is  to  diagnosticate  between  cancer, 
nasal  polypus,  and  the  results  produced  by  decayed  teeth.  Practically, 
the  diagnosis  between  carcinoma  and  sarcoma  is  of  slight  importance, 
as  the  treatment  is  the  same  for  both.  For  purposes  of  treatment  it  is 
sufficient  to  decide  that  the  tumor  is  malignant,  leaving  the  histological 
characters  to  be  decided  after  removal  of  the  crrowth.     Yet  there  are 


INJURIES  AND  DISEASES   OF  THE   DIGESTIVE   SYSTEM.        191 

certain  clear  distinctions  to  be  noted.  Sarcoma  involves  the  neighbor- 
ing parts,  but  not  the  glands,  while  carcinoma  readily  spreads  to  the 
glands.  The  spindle-celled  variety  of  sarcoma  has  a  tendency  to 
spread  along  the  periosteum,  and  becomes  softer  and  softer  with  each 
recurrence.  Probably  the  greatest  difficulty  lies  in  distinguishing 
between  malignant  tumors  and  inflammatory  processes.  A  sarcoma  is 
so  similar  to  an  abscess  as  to  puzzle  the  most  experienced.  Yet  there 
is  an  absence  of  the  inflammation  and  pain  which  always  precede  an 
abscess.  A  collection  of  pus  due  to  the  carious  root  of  a  tooth 
would  show  a  history  of  toothache  with  evidence  of  dental  caries. 
The  probe  is  not  always  a  sure  guide.  If  roughened  bone  be  felt,  it  is 
not  necessarily  necrosis,  for  the  bone  can  be  laid  bare  in  the  same 
manner  by  the  ravages  of  carcinoma  or  sarcoma. 

Tiratinciit. — Malignant  tumors  of  the  jaw  can  only  be  dealt  with  in 
one  way — complete  removal.  Within  the  last  few  years  reports  of 
cases  alleged  to  have  been  cured  by  injections  of  the  toxins  of  ery- 
sipelas with  bacillus  prodigiosus  have  appeared  in  the  medical  journals. 
In  several  cases  I  have  given  this  method  of  treatment  a  most  patient 
and  careful  trial,  but  in  every  instance  with  disappointing  results.  For 
the  present,  at  least,  our  hope  must  lie  in  the  direction  of  early  and 
complete  removal.  Recurrence  is  the  rule,  even  where  the  whole  of 
the  lower  jaw  is  taken  away. 

Operation  on  the  Upper  Jaw. — Small  tumors  confined  to  the 
alveolus  can  readily  be  removed  by  strong  cutting  bone-forceps, 
without  any  external  incision.  Tumors  of  considerable  size  have 
also  been  extirpated  in  this  manner,  although  the  difficulty  of  deliver- 
ing the  tumors  through  the  mouth  has  sometimes  been  so  great  as  to 
necessitate  an  incision  of  the  angle.  Large  tumors  involving  a  con- 
siderable portion  of  the  bone  require  resection  of  the  entire  jaw.  The 
method  is  as  follows  : 

First  Step. — An  incision  is  made  along  the  infraorbital  ridge  from 
the  malar  bone  to  a  point  just  below  the  inner  canthus,  thence  along 
the  side  of  the  nose  around  the  ala  to  the  middle  line,  and  lastly 
through  the  middle  line  of  the  upper  lip.  The  flap  formed  by  these 
incisions  is  dissected  from  the  bone  and  turned  outward,  divided  vessels 
are  ligated,  and  hemorrhage  arrested  by  pressure  with  hot  sponges. 

Second  Step. — The  incisor  teeth  on  the  affected  side  are  next 
remov^ed,  a  narrow-bladed  saw  passed  into  the  nostril,  and  the  hard 
palate  and  alveolus  divided.  With  a  Hey's  or  other  suitable  saw  sec- 
tion is  made  of  the  malar  bone  in  a  line  with  the  spheno-maxillary 
fissure  and  also  of  the  nasal  process  of  the  upper  jaw.  The 
saw  can  be  supplemented,  if  necessary,  with  bone-forceps.  Powerful 
forceps,  preferably  Fergusson's  lion-forceps,  are  next  made  to  grasp 
the  jaws,  and  by  a  powerful  wrench  the  bone  is  separated  from  its  con- 
nections, and  when  quite  loose  the  infraorbital  nerve  and  soft  palate  are 
severed  with  a  knife.  Should  any  diseased  tissue  still  remain,  it  can  be 
removed  with  gouge  and  chisel.  After  ligating  any  spurting  vessels 
the  cavity  can  be  filled  with  hot  sponges  for  a  few  minutes  and  all 
hemorrhage  arrested.  The  flap  is  now  replaced,  and  the  incision 
accurately  closed  through  its  whole  extent  with  sutures  of  catgut, 
except   the  lip,  where  silkworm  gut    is  perhaps  more    reliable.     The 


192  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

cavity  of  the  check  is  filled  with  iodoform  gauze,  and  an  external 
aseptic  dressing,  retained  by  a  light  flannel  or  gauze  bandage,  completes 
the  operation.  Even  before  the  advent  of  antiseptic  surgery  wounds 
of  the  face  healed  readily  by  first  intention,  and  these  operations  were 
wonderfully  free  from  mortality.  With  careful  asepsis  and  the  use  of 
disinfectant  mouth-washes  the  progress  of  recovery  is  rapid,  and  the 
sufferings  of  the  patient  are  reduced  to  a  minimum.  When  the  disease 
is  not  so  extensive  as  to  require  removal  of  the  whole  jaw  a  shorter 
incision  is  demanded.  Division  in  the  middle  line  of  the  lip  and  down 
to  the  ala  of  the  nose  may  be  sufficient.  When  the  orbital  plate  is  not 
involved,  the  saw  can  be  made  to  cut  horizontally  below  it,  and  the 
palate  when  healthy  may  be  spared  by  making  the  saw-cut  immediately 
above  it. 

Both  upper  jaws  have  occasionally  been  removed.  Probably  the 
best  of  the  methods  adapted  for  this  formidable  operation  is  that 
employed  by  Mr.  Dobson  of  Bristol,'  who  in  1872,  in  a  woman  of 
fifty-two,  divided  the  lip  in  the  middle  line  and  carried  the  incision  up 
each  side  of  the  nose. 

Operations  on  the  Lo^wer  Jaw. — When  the  tumor  is  small  and 
involves  only  the  alveolus,  it  can  be  removed  with  bone-forceps.  If 
the  mucous  membrane  covering  the  lower  jaw  be  freely  divided,  a 
great  portion  of  the  bone  can  be  removed  without  any  external  incision. 
In  extensive  disease  it  may  be  necessary  to  remove  one-half  or  the 
whole  of  the  bone.  When  an  external  incision  is  necessary,  it  can  be 
made  just  below  the  lower  border  of  the  bone  with  a  division  of  the 
lower  lip  in  the  middle  line  ;  but  this  later  incision  is  not  always  necessary. 
After  separating  the  bone  from  the  soft  parts  the  jaw  is  divided  in  the 
middle  line  and  strongly  drawn  outward,  while  the  soft  parts  are 
separated  back  to  the  articulation,  and  the  bone  disconnected  at  the 
jaw  by  dividing  the  ligaments  with  knife  or  scissors. 

The  question  of  saving  the  periosteum  cannot  be  entertained  if  the 
disease  is  malignant,  but  in  non-malignant  tumors  and  in  necrosis  this 
membrane  should  be  carefully  preserved.  All  bleeding  points  being 
secured  by  ligature,  cautery,  or  pressure,  the  incision  is  accurately 
closed  and  an  external  dressing  applied.  The  after-treatment  consists 
in  giving  fluid  nourishment  by  a  tube,  and  keeping  the  mouth  thoroughly 
disinfected  by  detergent  washes,  of  which  the  glycerinum  acidi  car- 
bolici  applied  with  a  camel's-hair  brush,  as  recommended  by  Heath,  is 
one  of  the  best. 

Diseases  of  the  Tempore -maxillary  Articulation. — This  is 
one  of  the  few  joints  which  escape  tuberculosis,  but  it  is  liable  to 
rheumatic  arthritis,  and  one  or  both  sides  may  be  the  seat  of  the  disease. 
It  is  chronic  in  character,  and  may  result  in  absorption  of  the  inter- 
articular  cartilage  and  in  outgrowths  from  the  bone.  True  ankylosis 
does  not  take  place.  This  disease  is  readily  diagnosed  from  its  painful 
and  chronic  character,  and  from  the  protrusion  of  the  chin  either 
directly  forward  or  to  one  side  according  as  the  disease  affects  one  or 
both  articulations. 

Acute  inflammation  is  the  result  of  injury,  or  it  may  be  the  exten- 
sion of  the  inflammatory  process  from  the  ear   or  some  neighboring 

1  Brit.  Med.  Journ.,  1873. 


INJURIES  AND   DISEASES   OF   THE  DIGESTIVE   SYSTEM.        1 93 

part.  It  then  follows  the  course  of  arthritis  in  other  parts,  and  should 
suppuration  take  place  ankylosis  is  not  an  unlikely  result. 

Closure  of  the  jaws  may  be  temporary  or  permanent.  The  tem- 
porary closure  is  usually  reflex  in  origin,  due  to  the  irritation  produced 
by  the  cutting  of  a  wisdom  tooth  or  the  failure  of  a  tooth  to  appear, 
owing  to  want  of  room  or  to  an  abnormal  position.  Some  of  the  cases 
are  hysterical.  Permanent  closure  may  be  due  to  ankylosis  following 
suppurative  arthritis.  Another  frequent  cause  is  cicatrization  following 
ulceration  or  injuries  of  the  mucous  membrane  of  the  cheek  ;  and  often 
through  profuse  salivation  the  lower  jaw  becomes  closely  bound  to  the 
upper,  so  that  the  teeth  cannot  be  separated  sufficiently  to  admit  solid 
food.  Sometimes  the  gums  are  adherent,  especially  if  there  is  necrosis 
of  the  alveolar  process. 

Treatment. — When  there  is  complete  ankylosis  or  intractable  closure 
the  operation  of  Esmarch  is  probably  the  best.  It  consists  in  the 
formation  of  an  artificial  joint  in  front  of  the  contraction,  and  admits 
of  at  least  limited  motion  of  the  jaw.  It  simply  consists  in  the 
removal  of  a  piece  of  bone  of  a  w^edge  shape  in  front  of  the  masseter 
muscle. 

Diseases  of  the  Tonsils. 

The  tonsils  are  subject  to  the  following  diseases :  tonsillitis,  hyper- 
trophy, calcareous  and  cheesy  concretions,  sarcoma,  and  carcinoma. 

Tonsillitis,  popularly  called  quinsy,  is  readily  distinguished  from 
other  diseases.  It  is  an  acute,  local,  inflammatory  affection,  generally 
following  exposure  to  cold,  but  depending  upon  a  more  remote  cause, 
such  as  a  tubercular  or  rheumatic  diathesis.  The  onset  of  the  attack 
is  marked  by  pains  in  the  limbs,  difficulty  of  swallowing,  chills,  and 
general  malaise.  The  temperature  rises  quickly,  and  may  reach  104° 
or  105°  F.  If  the  throat  be  examined  at  this  stage,  one  or  the  other 
tonsil  will  appear  swollen  and  violently  inflamed ;  the  redness  extends 
to  the  fauces,  and  the  glands  beneath  the  angle  of  the  jaw  are  swollen 
and  tender.  By  degrees  swallowing  becomes  more  and  more  painful. 
To  add  to  the  patient's  discomfort,  large  quantities  of  mucus  and  saliva 
are  constantly  being  secreted  and  must  be  expectorated.  Speech  is  at 
first  changed  to  a  nasal  twang,  and  later  may  be  almost  lost,  and  when 
the  patient  attempts  to  swallow  fluids  they  run  out  of  the  nose.  If 
resolution  does  not  take  place  (which  it  happily  does  in  many  cases  about 
the  third  or  fourth  day),  suppuration  occurs,  and  about  the  ninth  day 
the  abscess  ruptures,  and  the  patient,  experiencing  immediate  relief, 
speedily  recovers. 

Sometimes  the  second  tonsil  becomes  affected,  and  then  the  swell- 
ing is  so  great  as  almost  to  close  the  throat.  When  both  are  affected 
at  the  outset,  it  is  strong  presumptive  evidence  that  the  attack  is  due  to 
a  septic  cause. 

Treatment. — At  the  outset  a  brisk  purgative  should  be  giv'en,  and 
10  minims  of  tincture  of  belladonna  every  three  hours.  If,  after  forty- 
eight  hours,  the  inflammation  still  progresses,  the  case  will  probably 
go  on  to  suppuration.  A  hypodermic  of  morphin  with  atropia,  given 
at  bedtime,  will  give  great  relief  and  arrest  the  secretion  of  the  sticky 
mucus  which  is  so  distressing.     The  formation  of  pus  and  the  pointing 

13 


194  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

of  an  abscess  slunikl  not  be  waited  for.  An  early  incision  which  freely 
opens  up  the  tonsil  will  anticipate  the  abscess  and  cut  short  the  disease 
by  several  days.  In  lancing  the  tonsil  use  a  strai^^ht,  sharp  knife, 
wrapped  round  with  adhesive  plaster  to  within  an  inch  of  the  point. 
The  incision,  if  kept  within  the  line  of  the  molar  teeth,  will  run  no 
risk  of  woundiiiL^  the  internal  carotid  artery,  and,  as  the  parts  are  so 
sparint^ly  supplied  with   nerves,  the  operation  is  practically  painless. 

Follicular  tonsillitis  is  recot^nized  by  small,  yellowish-white  swell- 
ings about  the  size  of  a  pea  which  cover  the  surface  of  the  tonsil.  As 
these  little  abscesses  burst  they  form  ulcers,  which  may  run  together 
and  produce  large  ulcerated  patches  with  edges  swollen  and  under- 
mined. 

Hypertrophy  is  a  result  of  repeated  attacks  of  acute  tonsillitis.  It 
ma\',  however,  be  due  to  a  chronic  catarrhal  affection  of  the  tonsil. 
Tuberculous  children  are  specially  liable  to  this  affection.  The  enlarge- 
ment can  be  readily  seen  when  the  patient  opens  the  mouth,  and  in 
some  cases  the  glands  almost  touch  each  other.  Respiration  is  inter- 
fered with,  especially  during  sleep,  the  child  sleeping  with  the  mouth 
open  and  breathing  in  a  noisy  and  unpleasant  manner.  There  is  usually 
no  pain,  unless  there  be  attacks  of  acute  inflammation  ;  the  enlargement 
is  slow  and  steady. 

Treatment. — Excision  of  the  tonsil  is  the  only  effective  remedy. 
For  this  operation  several  tonsillotomes  have  been  invented,  of  which 
Mathieu's  is  perhaps  the  best  (Fig.  92).     An  assistant  should  steady 


Fig.  92. — Mathieu's  tonsillotome. 

the  patient's  head,  and  with  his  fingers  below  the  angle  of  the  jaw- 
press  the  tonsils  inward.  The  instrument  is  applied  (taking  care  that 
the  lower  portion  of  the  tonsil  lies  well  within  the  grasp  of  the  instru- 
ment), and  with  a  rapid  movement  the  required  portion  of  the  gland  is 
removed.  Bleeding  has  often  proved  troublesome  after  removal  of  the 
tonsil,  the  hemorrhage  coming  from  the  tonsillar  branch  of  the  facial. 
To  arrest  it,  pressure  should  be  made  from  the  inside  with  a  piece  of 
gauze  held  in  a  pair  of  forceps  while  the  fingers  make  pressure  from 
without.  In  this  way  the  tonsil  can  be  compressed  so  as  to  control  the 
flow  of  blood,  and  this  can  be  further  aided  by  the  application  of  strong 
astringent  solutions,  as  the  tincture  of  perchlorid  of  iron.  It  is  rarely 
that  ligation  of  the  carotid  has  to  be  resorted  to. 

Calcareous  and  cheesy  concretions  are  found  of  various  sizes, 
sometimes  large  enough  to  increase  the  size  of  the  tonsil  to  an  enor- 
mous extent,  or  so  small  that  they  are  only  accidentally  discovered 
when  the  tonsil  is  excised.  Besides  the  discomfort  caused  by  their 
size,  concretions  often  cause  inflammation  of  the  tonsil. 

Treatment. — Remove  the  concretion  by  cutting  down  upon  it  and 
turning  it  out  of  its  bed,  or  by  removing  the  redundant  portion  of  the 
tonsil  in  which  the  concretion  is  lodged. 


INJURIES  AND  DISEASES  OF  THE  DIGESTIVE   SYSTEM.        1 95 

Tumors  of  the  tonsil  are  rare,  the  form  most  hkely  to  be  met  with 
being  sarcoma. 

Sarcoma  occurs  in  young  persons,  usually  below  twenty  years  of 
age.  It  forms  a  tumor  which  steadily  increases  in  size  and  soon  begins 
to  ulcerate,  death  often  resulting  from  hemorrhage.  The  growth  forms 
a  well-defined  tumor  which  does  not  involve  the  neighboring  glands. 
This  feature  distinguishes  it  from  carcinoma. 

Carcinotna  of  the  tonsil  is  of  the  epithelial  variety.  It  is  seldom 
found  as  a  primary  affection,  but  as  an  extension  from  the  disease  in 
adjoining  organs  it  is  not  uncommon.  In  the  early  stages  a  primary 
cancer  of  the  tonsil  is  difficult  of  diagnosis,  and  is  generally  set  down  as 
a  simple  hypertrophy  of  the  gland.  As  the  disease  progresses,  how- 
ever, the  lymphatics  become  involved,  nodules  form  about  the  angle  of 
the  jaw,  and  the  general  characters  of  carcinoma  become  manifest. 

Treatment. — Unfortunately,  even  the  total  extirpation  of  the  tonsil  is 
unsatisfactory  for  either  form  of  malignant  disease,  as  the  growth  is 
almost  sure  to  return.  In  sarcoma,  the  tumor  being  more  sharply 
defined  and  the  neighboring  parts  free  from  disease,  the  prospect  of 
cure  is  better.  The  tonsil  can  be  removed,  either  by  the  mouth  or  by 
an  external  incision  extending  for  about  three  or  four  inches  along  the 
anterior  border  of  the  sterno-mastoid  muscle,  beginning  at  the  ear  and 
ending  below  the  level  of  the  tumor.  If  necessary,  a  second  incision 
may  be  made  along  the  lower  border  of  the  jaw.  Dissecting  through 
this  space,  the  tumor  is  reached,  lying  within  the  superior  constriction 
of  the  pharynx.  A  more  radical  operation,  however,  is  necessary,  and 
the  method  devised  by  Czerny  is  probably  the  best.  After  a  pre- 
liminary tracheotomy  he  makes  an  incision  from  the  angle  of  the  mouth 
to  the  anterior  border  of  the  masseter  muscle,  and  from  this  point 
downward  to  the  os  hyoides.  Mikulicz  makes  his  incision  from  the 
mastoid  process  to  the  greater  cornu  of  the  hyoid  bone.  In  either 
operation  the  lower  jaw  is  divided  about  the  position  of  the  first  molar 
tooth,  and  turned  backward  so  as  to  give  room  for  the  deep  dissection. 

The  Pharynx. 

The  diseases  of  the  phar>mx  requiring  special  attention  from  a 
diagnostic  standpoint  are  retropharyngeal  abscess  and  tumors  of  the 
pharynx. 

Retropharyng-eal  abscess  is,  in  many  cases,  a  result  of  caries  of  the 
cervacal  vertebrae.  It  may,  however,  occur  as  a  sequel  of  scarlatina  or 
as  an  extension  of  inflammation  from  neighboring  parts,  especially  the 
glands.  It  is  most  commonly  met  with  in  tubercular  children.  The 
first  symptoms  to  attract  attention  are  difficulty  of  swallowing  and 
dyspnea.  If  the  patient  be  subject  to  disease  of  the  cervical  vertebrae, 
these  symptoms  are  almost  certain  to  indicate  an  abscess  between  the 
back  of  the  pharynx  and  the  cervical  vertebrae.  Examine  the  patient's 
mouth,  and  you  will  find  projecting  from  the  back  of  the  pharynx, 
usually  to  one  side  of  the  middle  line,  a  swelling  which  fluctuates,  is 
soft  and  boggy,  and  does  not  disappear  on  pressure.  The  patient  in 
some  cases  cannot  move  the  head  without  intense  pain,  but  this  is  due 
to  disease  in  the  vertebrae.     As  the  abscess  increases  in  size  it  extends 


196  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

laterally,  and  if  allowed  to  go  untreated  causes  a  bulging  in  the  neck 
just  behind  tiie  sterno-mastoid  muscle.  Rarely  it  burrows  into  the 
posterior  mediastinum. 

Trcatnioit. — As  soon  as  the  presence  of  pus  is  determined  an  open- 
ing should  be  made  into  the  tumor.  The  patient's  head  being  steadied 
by  an  assistant  and  held  slightly  forward,  depress  the  tongue,  and  with 
a  long  straight  bistoury  make  an  incision  near  the  middle  line  into  the 
abscess.  The  bodies  of  the  cervical  vertebrae  lie  directly  behind,  so 
that  there  is  no  danger  of  cutting  any  important  structure.  If  the 
abscess  is  large,  and  there  is  danger  of  suffocating  the  patient  by  too 
rapid  an  outflow  of  pus,  an  aspirator  can  first  be  used  to  remove  a  suf- 
ficient quantity  to  lessen  the  swelling,  after  which  the  abscess  can  be  laid 
freely  open  with  a  knife. 

When  the  abscess  is  of  old  standing  and  points  in  the  neck  behind 
the  sterno-mastoid,  it  can  be  opened  externally.  An  incision  is  made 
through  the  skin  at  the  bulging  point,  and,  after  the  manner  of  Hilton, 
a  grooved  director,  followed  by  dressing-forceps,  is  pushed  into  the 
abscess  and  the  opening  freely  dilated.  It  should  then  be  thoroughly 
irrigated  and  dressed  in  the  usual  manner.  This  method  is  in  many 
ways  preferable  to  the  opening  on  the  inside,  as  it  allows  external 
drainage  and  averts  the  unpleasantness  of  pus  discharging  into  the 
mouth. 

Tumors  of  the  pharynx  are  rare.  In  most  cases  the  growths 
are  congenital,  and  may  be  papillomatous,  fatty,  or  fibroid  in  character. 
If  the  tumor  pulsates,  it  is  likely  to  prove  an  aneurysm  of  the  internal 
carotid  artery. 

Diagnosis  of  Diseases  and  Injuries  of  the  Esophagus. 

The  following  are  the  conditions  to  be  sought  for  in  an  examination 
of  the  esophagus : 

Malformations. — Branchial  fistuL-e  may  occur  at  any  of  the 
three  positions  which  correspond  to  the  branchial  clefts  of  the  embryo. 
The  lowest  of  them  is  at  the  sternal  end  of  the  clavicle ;  the  middle, 
opposite  the  thyroid  cartilage ;  and  the  highest,  between  the  thyroid 
cartilage  and  the  hyoid  bone.  A  permanent  congenital  fistula  existing 
at  one  or  more  of  these  points  may  be  set  down  as  a  branchial  fistula. 
Such  fistulje  may  be  capable  of  admitting  nothing  but  a  probe,  though 
the  external  opening  may  be  much  larger  farther  in,  and  may  expand 
to  the  dimensions  of  a  good-sized  cyst.  When  pressure  is  made  along 
the  course  of  the  fistula  a  mucous  fluid  is  found  to  exude.  Sometimes 
it  suppurates  and  gives  rise  to  a  constant  discharge  of  pus. 

Pouches,  or  diverticula  in  the  esophagus,  with  stricture,  are  some- 
times congenital.  An  infant  may  be  found  to  suck  well,  but  the  milk, 
instead  of  being  swallowed,  runs  out  of  the  mouth.  As  the  child 
receives  no  nourishment,  emaciation  rapidly  follows.  An  important 
symptom  of  dilatation  above  a  stricture  is  the  regurgitation  of  large 
quantities  of  milk  at  a  time,  and  the  evidence  that  the  milk  has  never 
reached  the  stomach,  not  being  curdled  nor  of  acid  reaction. 

Stricture  of  the  esophagus  may  be  spasmodic,  cicatricial,  malig- 
nant, or  due  to  the  pressure  of  a  tumor. 


INJURIES  AND   DISEASES    OF   THE   DIGESTIVE   SYSTEM.        l^'j 

Spasmodic  stricture  is  met  with  in  young  or  middle-aged  women  of 
hysterical  temperament.  The  patient  complains  of  a  sensation  as  if  a 
ball  were  rising  in  her  throat,  the  so-called  "  globus  hystericus."  The 
difficulty  of  swallowing  comes  on  suddenly  without  any  perceptible 
cause,  and  it  may  be  that  the  dysphagia  is  confined  to  certain  articles 
of  food,  or  the  patient  may  swallow  perfectly  when  unobserved.  Pass 
a  bougie  down  through  the  esophagus,  and  it  will  be  found  to  reach 
the  stomach  without  obstruction. 

Fibrous  or  cicatricial  stricture  has  a  well-defined  cause.  A  child 
gets  hold  of  some  lye  or  other  caustic  liquid  and  drinks  it,  severely 
burning  the  mouth  and  digestive  tract.  In  the  process  of  healing  the 
tissues  contract,  and  the  esophagus  at  one  or  two  points  becomes  almost 
closed.  The  most  common  seat  of  such  stricture  is  at  the  level  of  the 
cricoid  cartilage ;  that  is  to  say,  at  the  beginning  of  the  esophagus. 
The  history  of  these  cases  is  usually  very  clear  and  the  diagnosis  not 
difficult.  Food  is  taken  into  the  mouth,  passes  beyond  the  pharjmx, 
but  sticks  in  the  gullet  and  soon  returns.  The  patient  is  emaciated  and 
undeveloped. 

In  the  diagnosis  of  stricture  due  to  any  cause  the  passage  of  the 
bougie  (Fig.  93)  gives  the  most  satisfactory  information.     It  is  done  as 


Dilators  for  esophageal  stricture. 


follows  :  The  patient,  seated  in  a  steady  chair,  holds  the  head  well  back 
so  as  to  bring  the  mouth  and  esophagus  in  line.  The  bougie,  moistened 
with  hot  water,  is  passed  to  the  back  of  the  pharynx,  and  while  the 
patient  attempts  the  act  of  swallowing,  it  is  pressed  gently  into  the 
esophagus.  Should  resistance  be  met  with,  no  force  should  be  used, 
but  the  instrument  withdrawn  and  gently  pushed  in  another  direction. 
Bougies  of  different  sizes  should  then  be  employed,  in  the  hope  that 
one  can  be  made  to  pass  through  the  stricture  and  into  the  stomach. 
Many  forms  of  bougie  have  been  invented.  Those  most  commonly 
employed  consist  of  whalebone  stems  upon  which  ivory  knobs  of  dif- 
ferent sizes  can  be  screwed. 

Malignant  or  cancerous  stricture  is  found  in  persons  about  or 
after  the  period  of  middle  life,  and  more  frequently  in  men  than  in 
women.  The  symptoms  develop  slowly.  The  difficulty  of  swallowing 
comes  on  by  degrees — first  as  regards  solids,  and  later  liquids.  Pro- 
gressive emaciation  is  noticed,  and  there  may  be  a  slight  discharge  of 
bloody  mucus  and  pus.  In  cases  of  this  kind  the  glands  of  the  neck 
should  be  carefully  examined,  and  a  systematic  search  should  be  made 
for  cancer  in  other  organs.  The  passage  of  bougies,  if  resorted  to  at 
all,  must  be  done  with  great  care,  lest  they  greatly  aggravate  the  dis- 
ease. There  is  another  diagnostic  method  which  is  perfectly  harmless 
and  generally  reliable.     This  is  auscultation.     If  the  patient  be  asked 


198  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

to  take  a  mouthful  of  water,  and  the  stethoscope  be  placed  over  the 
lower  third  of  the  esophagus,  the  fluid  can  be  heard  to  trickle  through 
the  stricture. 

The  esophagoscope  is  an  instrument  that  may  sometimes  be 
employed  to  advantage  in  the  diagnosis  of  stricture,  carcinoma,  and 
foreign  bodies  in  the  esophagus.  It  is  an  endoscopic  instrument  which 
can  be  passed  through  the  pharynx  and  down  the  whole  length  of  the 
gullet.  An  electric-light  attachment  illuminates  each  part  as  it  comes 
into  view.  Considerable  experience  and  dexterity  are  required  in  its 
management. 

Trcatiiiciit. — Several  methods  of  treating  stricture  of  the  esophagus 
are  practised : 

1.  Dilatatio)i  by  Bougies. — When  the  stricture  is  simple  and  not  very 
rigid  the  passage  of  the  largest  bougie  which  can  be  inserted  is  daily 
employed,  and  the  size  increased  as  the  stricture  dilates.  The  patient 
is  fed  on  liquids,  milk,  eggs,  strong  broth,  etc. 

In  many  cases  the  esophagus  above  the  stricture  is  sacculated, 
rendering  it  impossible  to  pass  instruments  from  above. 

2.  Retrograde  dilatation  was  first  performed  by  Von  Bergmann  in 
1883.  The  first  step  of  the  operation  deals  with  the  stomach,  and  is 
either  a  gastrotomy  or  a  gastrostomy  according  to  circumstances.  The 
gastric  opening  should  be  large  enough  to  admit  one  or  two  fingers 
besides  the  dilating  instruments.  A  larger  opening  is  unsafe,  as  it 
allows  leakage  of  the  stomach-contents  into  the  peritoneal  cavity, 
while  too  small  an  opening  makes  it  difficult  to  find  the  cardiac  orifice 
(Woolsey).  The  second  step  is  the  dilating  of  the  stricture.  With  the 
fingers  in  the  stomach  opening  find  the  cardiac  orifice,  and  guide  a 
strong  uterine,  pharyngeal,  or  Otis  dilator  up  through  the  stricture  and 
stretch  it. 

Instead  of  dilators,  it  may  be  more  expedient  to  use  other  methods 
in  stretching  the  strictured  part.  A  thread  can  be  swallowed  to  the 
end  of  which  is  attached  a  shot,  or  a  knot  can  replace  the  shot.  By 
means  of  this  thread  bougies  can  be  pulled  up  from  below.  Abbe 
followed  a  plan  in  his  second  case  which  appears  to  answer  the  pur- 
pose admirably.  After  opening  the  stomach  the  stricture  was  dilated 
as  much  as  possible  in  the  manner  just  described.  He  then  by  means 
of  a  "  string  saw  "  cut  the  remaining  tissue,  so  as  to  admit  of  complete 
dilatation.  The  wounds  were  closed,  and  after  a  few  days  bougies  were 
passed  from  above. 

Bernays  employs  a  "  rosary  bougie,"  made  by  taking  the  olivary 
bulbs  from  the  ordinary  whalebone  bougies,  and,  after  perforating 
them  in  their  long  axes,  he  threads  them  on  strong  silk.  The  smallest 
size  is  placed  at  the  upper  end  of  the  chain,  and  kept  from  slipping  by 
a  knot  on  the  thread.  By  regular  gradation  the  size  is  increased  to  the 
largest  bulb  that  can  be  used. 

Treatment  of  Malignant  Strictiirc. — For  obvious  reasons  the  use  of 
dilating  bougies  is  not  suitable  in  malignant  stricture.  Two  methods 
are  left  to  us,  the  one  dealing  with  an  artificial  opening,  the  other  with 
the  wearing  of  a  tube  to  keep  the  stricture  permanently  dilated. 

Excision  of  the  growth  has  been  resorted  to,  but  the  cases  where 
such  treatment  is  available  are  few  and  far  between. 


INJURIES  AND   DISEASES   OF   THE   DIGESTIVE   SYSTEM.        1 99 

Esophagostomy  is  the  operation  of  making  an  artificial  opening  in 
the  esophagus.  It  of  course  must  be  made  below  the  stricture,  and,  as 
it  is  impossible  to  prove  how  far  down  the  esophagus  the  disease 
extends,  the  operation  is  very  unsatisfactory.  The  incision  is  the  same 
as  for  esophagotomy,  only  lower  down. 

When  an  artificial  opening  has  to  be  resorted  to,  the  stomach  offers 
the  best  field,  as  it  is  farther  from  the  disease  and  is  comparatively  easy, 
and  yet  the  results  of  gastrotomy  for  malignant  disease  are  exceedingly 
bad.  Like  all  operations  which  aim  only  to  relieve,  and  not  to  cure,  it 
can  never  be  looked  upon  with  favor.  This,  however,  it  will  do — it 
will  (particularly  if  resorted  to  before  he  is  exhausted)  allow  the  patient 
to  receive  nourishment  and  prevent  starvation,  and  lessen  the  suffering 
which  attends  ev'ery  attempt  to  pass  food  along  the  esophagus. 

Of  the  many  methods  of  performing  gastrostomy,  that  of  Witzel  is 
probably  the  best.  In  this  operation  the  fistula  is  made  to  pass  through 
both  the  rectus  and  transversalis  muscles.  As  the  fibers  of  the  muscles 
run  at  right  angles  to  each  other,  their  contraction  may  be  relied  upon 


Fig.  94. — Witzel's  method  for  gastrostomy, 
showing  application  of  sutures  in  wall  of 
stomach,  imbedding  tube  obliquely  therein. 


Fig.    95. — Sutures   tied,    completely    im- 
bedding tube  for  some  distance. 


as  an  efficient  sphincter.  The  second  important  feature  of  this  ope- 
ration is  the  enfolding  of  the  tube  in  the  wall  of  the  stomach,  the 
stomach-wall  being  stitched  over  the  tube  so  as  to  form  an  oblique 
cone  (Figs.  94,  95). 

The  Ssabanejew-Frank  operation  may  be  preferred  by  some  ope- 
rators. It  consists  in  drawing  up  a  cone  of  the  stomach  through  the 
ordinary  Fenger  incision  and  under  a  bridge  of  skin  to  a  point  above 


200 


SL.RG/CAL   D/AGA'OS/S  AND    TREATMENT. 


the  border  of  the  ribs,  where  it  is  fixed  and  opened.  This  secures  a 
curved  fistula  with  a  bridge  of  stretched  skin  acting  as  a  sphincter 
(Figs.  96-99). 


P^GS.  96-99. — Frank's  method  of  gastrostomy  in  carcinoma  of  the  esophagus. 

As  an  improvement  upon  any  of  the  foregoing  methods  Symonds 
has  invented  tubes  which  can  be  passed  down  to  the  stricture,  and,  fitting 
accurately  there,  liquids  can  be  passed  through  without  difficulty.  The 
tubes  are  from  4  to  6  inches  in  length,  made  of  gum  elastic  upon  a  silk 
web,  and  having  a  highly  polished  surface  within  and  without.  At  the 
upper  end  the  tube  is  funnel-shaped  to  rest  upon  the  stricture,  and 
slightly  flattened  anteriorly  to  fit  the  more  accurately  against  the 
cricoid  cartilage.  Two  perforations  in  the  rim  of  the  funnel  are  for  the 
attachment  of  a  silk  thread.  In  the  introduction  of  the  tube  the 
stricture  is  first  accurately  located  and  its  position  indicated   on  the 


INJURIES  AND   DISEASES   OF   THE   DIGESTIVE   SYSTEM.        20I 

bougie.  With  a  whalebone  guide  the  tube  is  slipped  very  gently  down 
to  the  stricture,  and  through  it  until  the  funnel  meets  with  resistance. 
The  guide  is  withdrawn,  and  the  silk  thread  which  is  attached  to  the 
funnel  is  then  made  fast  to  the  ear  or  secured  to  the  cheek  with  adhe- 
sive plaster.  After  two  or  three  days  it  will  be  found  that  a  larger 
tube  can  be  inserted  as  the  stricture  dilates.  The  second  and  larger 
tube  may  be  left  in  position  several  months. 

II.  DISEASES  AND  INJURIES  OF  THE  ABDOMEN. 

Examination  of  the  Abdomen. — For  this  examination  the 
patient  should  lie  upon  a  firm  table  or  bed,  the  head  and  shoulders 
should  be  slightly  raised,  and  the  knees  flexed  to  an  angle  of  about 
ninety  degrees.  This  posture  relaxes  the  abdominal  muscles  suf- 
ficiently. If  the  head  and  shoulders  be  raised  too  high,  the  antero- 
posterior diameter  of  the  abdomen  will  be  increased  and  it  becomes 
more  difficult  to  palpate  the  organs.  The  abdominal  cavity  includes 
everything  within  the  peritoneum,  and  for  diagnostic  purposes  it  is 
convenient  to  consider  the  abdominal  and  pelvic  regions  as  one  cavity. 
The  anterior  wall  of  this  cavity  is  lozenge-shaped,  the  four  corners  of 
the  lozenge  being  at  the  ensiform  cartilage,  the  pubes,  and  the  loins. 
This  wall  is  composed  of  skin,  fat  of  indefinite  thickness,  muscles, 
fascia,  and  peritoneum.  In  our  examination  it  lies  between  us  and  the 
structures  within,  rendering  palpation  difficult,  and  by  the  contraction 
of  the  muscles  presenting  appearances  which  are  likely  to  mislead. 
Patients  wath  thin,  lax  abdominal  walls  are  easily  examined.  The  most 
difficult  subjects  are  males  whose  abdominal  walls  are  thick  and  fat. 

It  is  customary  to  divide  the  abdomen  into  nine  regions.  This  is 
done  by  drawing  upon  the  skin  two  vertical  and  two  horizontal  lines. 
The  vertical  lines  e.xtend  from  the  middle  of  Poupart's  ligament  to  the 
cartilage  of  the  eighth  rib.  The  upper  transverse  line  is  at  the  level  of 
the  ninth  costal  cartilage,  and  the  lower  at  the  highest  point  of  the  crest 
of  the  ilium.  Beginning  from  above  downward,  w^e  have  thus  mapped 
out,  in  the  middle,  the  epigastric,  umbilical,  and  hypogastric  regions  ; 
on  the  right  side,  the  right  hypochondriac,  the  right  lumbar,  and  the 
right  iliac ;  on  the  left  side  are  the  left  hypochondriac,  lumbar,  and 
iliac.     The  contents  of  these  regions  are  as  follows  : 

In  the  epigastric  region  are  found,  from  before  backward,  the  left 
lobe  of  the  liver;  part  of  the  anterior  wall  of  the  stomach  with  the 
cardiac  and  pyloric  orifices  ;  the  gastro-hepatic  omentum  and  foramen 
of  Winslow.  Close  to  the  foramen  are  the  hepatic  artery,  the  hepatic 
and  cystic  ducts,  and  the  origin  of  the  ductus  communis  choledochus, 
the  portal  vein,  and  the  vagus.  Behind  the  stomach  lie  the  duodenum, 
the  pancreas,  the  celiac  axis,  the  superior  mesenteric  artery,  the  solar 
plexus,  the  aorta,  and  the  vena  cava  inferior. 

The  right  hypochondriac  region  is  occupied  by  the  right  lobe  of  the 
liver,  behind  which  is  the  gall-bladder,  a  small  portion  of  the  transverse 
colon,  and  the  upper  end  of  the  right  kidney  with  its  suprarenal  capsule. 

The  left  hypochondriac  region  contains  the  cardiac  end  of  the 
stomach,  the  spleen  and  gastro-splenic  omentum,  the  left  flexure  of  the 
colon,  the  upper  end  of  the  left  kidney,  and  its  suprarenal  capsule. 


202  SL.KC/C.1L    n/A GNOSIS  AXD    'JKKATMEN7\ 

The  umbilical  region  is  occupied  by  the  bulk  of  the  small  intestine, 
the  great  omentum,  mesentery,  aorta,  and  vena  cava  inferior. 

The  lumbar  regions  contain  the  ascending  colon  on  the  right,  the 
descending  colon  on  the  left,  the  right  and  left  kidney  respectively  with 
their  ureters,  some  loops  of  small  intestine,  and  ccllulo-adispose  tissue. 

The  hypogastric  region  contains  the  great  omentum,  portions  of 
the  small  intestine,  the  bladder  when  distended,  or  the  uterus  when 
enlarged. 

The  iliac  regions  contain  on  the  riglit  side  the  cecum,  and  on  the 
left  the  sigmoid  flexure. 

Subjective  Symptoms. — The  patient  suffering  from  disease  or 
injury  in  the  abdomen  may  complain  of  pain,  fulness,  weight,  distention, 
burning,  or  undue  motion.  Of  these  pain  is  the  most  important  and 
most  frequently  met  with.  It  may  be  sudden  in  its  onset,  as  in  colic, 
or  it  may  be  chronic,  as  in  gastric  carcinoma.  We  can  form  a  fairly 
reliable  opinion  of  the  nature  of  a  case  from  the  character  of  the  pain 
as  described  by  the  patient. 

Position  of  the  Pain. — As  a  rule,  when  pain  is  referred  to  one  par- 
ticular part  it  indicates  disease  in  the  organ  or  structure  which  is  the 
seat  of  pain.  Care  must  be  taken  to  differentiate  between  pain  in  the 
abdominal  wall  and  in  the  internal  organs.  If  the  skin  is  affected,  the 
pain  is  sharply  localized ;  there  is  tenderness  to  touch,  and  there  may 
be  redness,  showing  erythema,  ulceration,  erysipelas,  etc.  Pain  in  the 
nerves  is  generally  neuralgic  ;  there  is  usually  tenderness  at  one  or 
more  points ;  it  has  a  sudden  onset  and  an  equally  sudden  disappear- 
ance, and  there  is  absence  of  fever.  Herpes  zoster  is  attended  with  vio- 
lent pain  before  the  appearance  of  the  vesicular  eruption.  Disease  of 
the  vertebrae  or  the  pressure  of  an  aneurysm  on  the  spinal  column  pro- 
duces a  pain  which  is  intermittent  in  character,  and  is  felt  in  the  middle 
line  between  the  ensiform  cartilage  and  the  umbilicus.  When  the  mus- 
cles and  fascia  are  affected  the  pain  increases  with  motion  of  these 
muscles,  as  in  coughing,  laughing,  or  bending  the  body. 

Sudden  pain  occurring  in  paroxysms,  attended  with  vomiting,  rapid 
pulse,  cold  sweats,  pallor  of  the  skin,  and  more  or  less  collapse,  is  sug- 
gestive of  intestinal,  renal,  biliary,  or  uterine  colic.  If  it  occur  in  the 
course  of  typhoid  fever  or  ulceration  of  the  stomach  or  intestine,  it  is 
very  suggestive  of  perforation  and  escape  of  the  contents  of  the  hollow 
viscera  into  the  peritoneal  cavity.  The  rapid  development  of  peri- 
tonitis would  confirm  the  suspicion.  But  the  severity  and  suddenness 
of  the  pain  must  not  be  explicitly  relied  upon.  Such  pain  is  found  in 
simple  gastralgia,  enteralgia,  or  obstruction  of  the  intestine.  These 
will  receive  closer  attention  when  respectively  dealt  with. 

Pain  over  the  whole  abdomen  is  generally  caused  by  peritonitis  or 
rheumatism.  If  peritonitis,  there  is  great  tenderness  on  pressure,  the 
limbs  are  drawn  up  to  relax  the  abdominal  walls,  and  the  weight  of  the 
bed-clothes  cannot  be  borne.  Rheumatism  is  recognized  by  the  slight 
amount  or  absence  of  fever,  by  the  aggravation  caused  by  movement, 
by  the  presence  of  uric  acid  and  urates  in  excess. 

Fulness,  weight,  and  distention  are  subjective  symptoms  of  minor 
importance,  due  to  enlargement  or  displacement  of  the  various  organs, 
the  presence  of  tumors,  or  the  presence  of  inflammation. 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE  SYSTEM       203 

Objective  Symptoms. — An  examination  of  the  abdomen  embraces 
inspection,  palpation,  percussion,  auscultation,  and,  in  exceptional  cases, 
exploratory  puncture  or  exploratory  incision. 

Inspection. — Stand  at  the  patient's  feet,  and  as  he  lies  in  the  posi- 
tion already  described  any  changes  in  form  or  contour  can  be  readily 
noted. 

The  size  and  shape  of  the  abdomen  are  the  first  to  be  considered.  In 
children  the  abdomen  is  naturally  more  protuberant  and  proportionally 
larger  than  in  adults.  Large  eaters  have  large  bellies,  and  some  peo- 
ple have  their  abdominal  walls  and  omentum  enormously  thickened 
with  fat.  When  due  to  such  conditions  the  abdominal  enlargement  is 
proportionate  to  the  enlargement  of  other  parts  of  the  body,  while  in 
ascites  or  tumors  the  size  of  the  abdomen  strongly  contrasts  with  the 
wasted  condition  of  the  chest  and  limbs. 

Ascites  is  characterized  by  general  enlargement,  and  the  contained 
fluid  gravitates  to  the  flanks,  causing  them  to  bulge  outward,  while  the 
anterior  wall  is  flattened.  Change  of  position  will  be  followed  by  cor- 
responding change  in  shape,  the  upper  parts  becoming  flattened,  while 
the  lower  bulge.  In  excessive  distention  from  ascites  these  signs  do 
not  hold  good,  for  all  parts  are  tense ;  the  swelling  is  uniform  and 
unchanged  by  posture. 

Accumulation  of  gas  in  the  intestine  is  an  important  symptom.  It 
may  be  due  to  simple  indigestion,  and  in  such  a  case  is  usually  of  slight 
importance.  It  is  an  accompaniment  of  typhoid  fever.  Surgically,  it  is 
met  with  as  one  of  the  alarming  results  of  peritonitis  following  opera- 
tions or  as  the  effect  of  obstruction  in  the  large  intestine. 

Large  tumors  of  especial  organs,  as  the  spleen,  liver,  or  gall-bladder, 
may,  on  inspection,  present  the  appearance  of  general  enlargement  of 
the  abdomen,  but  further  examination  by  palpation  and  percussion  will 
locate  a  tumor  in  the  position  to  which  it  belongs  unless  it  is  so  large 
as  to  fill  the  abdominal  cavity. 

Local  Enlargement. — When  we  observe  a  local  enlargement  of  any 
part  of  the  abdomen,  our  attention  is  naturally  drawn  to  the  organ  or 
organs  which  normally  occupy  that  position.  And  this  is  a  pretty  safe 
rule,  for  a  tumor  of  any  organ  always  begins  to  grow  in  the  normal 
position  of  that  organ,  and  encroaches  by  degress  upon  the  neighbor- 
ing regions.  Thus  a  tumor  of  the  kidney  may  be  felt  in  the  umbilical 
region,  but  its  first  appearance  is  in  one  or  the  other  lumbar  space,  and 
it  never  reaches  the  umbilical  until  it  has  filled  the  lumbar  region. 

The  color  of  the  skin  is  not  very  suggestive.  In  ascites  and  edema 
it  is  pale  and  glistening ;  in  Addison's  disease  there  may  be  an  areola ; 
in  pregnancy  there  is  not  infrequently  a  bronzing  of  the  skin  between 
the  pubis  and  umbilicus.  Enlarged  veins  may  be  easily  perceptible 
beneath  the  skin,  as  in  cirrhosis  of  the  liver  or  in  cases  where  a  tumor 
exists  large  enough  to  make  pressure  upon  the  vena  cava  and  thus 
interfere  with  the  return  circulation. 

Movements. — The  upper  portion  of  the  abdomen  takes  part  in  the 
movements  of  normal  respiration,  especially  in  males.  Movement  is 
restricted  in  peritonitis,  in  general  enlargement,  and  when  tumors  occupy 
the  upper  portion  of  the  abdomen.  When  tumors  are  in  contact  with 
the  aorta,  pulsation  may  be  communicated  to  the  morbid  growth  and 


204  SURGICAL    DIAGXOSIS  AND    TREATMENT. 

be  perceptible   through   the  abdominal  walls.     If  the  patient  is  placed* 
upon   his  hands  and  knees,  the  tumor  falls  awa)-  from  the  aorta  and 
pulsation  ceases. 

Movements  of  the  stomach  may  be  observed  in  thin  subjects,  espe- 
cially when  the  viscus  is  much  enlarged  or  displaced  downward  ;  hence, 
dilatation  may  be  diagnosticated  by  inspection  alone.  Sometimes  peri- 
staltic waves  of  the  stomach  may  be  observed  passing  from  left  to  right. 
If  intense  and  persistent,  this  condition  is  spoken  of  as  "  peristaltic  rest- 
lessness "  of  the  stomach. 

Peristaltic  movement  of  the  intestines  is  a  common  symptom  when 
there  is  narrowing  or  obstruction  of  the  lumen  of  the  bowel.  In  the 
case  of  the  large  intestine  the  wave  may  be  traced  along  the  course  of 
the  colon,  but  when  the  small  intestine  is  involved  the  movx^mcnt  is 
observed  in  the  umbilical  region. 

Palpation. — Of  all  the  methods  of  examination  of  the  abdomen,  this 
is  the  most  important,  and  can  be  brought  to  a  high  state  of  efficiency 
by  cultivation.  The  abdominal  walls  must  be  well  relaxed  by  raising 
the  head  and  shoulders  and  by  bending  the  knees.  If  the  examining 
hand  is  cold,  dip  it  in  warm  water,  and  two  points  will  have  been 
gained — the  sense  of  touch  will  be  more  acute,  and  the  abdominal  mus- 
cles will  not  retract,  as  they  are  sure  to  do  when  they  are  touched  by 
icy  fingers.  The  recti  muscles  are  especially  prone  to  contract,  and 
great  care  is  necessary  at  times  to  distinguish  this  rigidity  from  a  tumor. 
The  point  is  readily  settled  by  directing  the  patient  to  throw  the  rectus 
into  action  while  the  fingers  are  placed  upon  it.  Most  patients  cause 
contraction  of  the  recti  by  the  simple  movement  of  raising  the  head 
from  the  pillow.  If  this  does  not  succeed,  direct  the  patient  to  sit  up, 
when  the  very  first  movement  wall  be  contraction  of  the  recti.  Per- 
manent localized  contraction  of  the  muscles  is  indicative  of  inflamma- 
tion in  the  parts  beneath. 

Palpation  should  be  commenced  by  placing  the  palm  of  the  hand 
over  the  umbilical  region,  and  by  a  gentle  motion  (rolling  the  skin 
over  the  subjacent  parts)  pressing  it  steadily  downward.  If  no  tumors 
be  felt,  the  hand  without  much  difficulty  can  be  made  to  feel  the  spinal 
column  and  the  aorta  down  to  its  bifurcation.  From  this  region  the 
palm  is  rotated  outward,  and  the  ulnar  side  of  the  hand  pressed  gently 
but  deeply  into  the  lumbar  and  iliac  regions.  This  will  enable  you  to 
palpate  the  brim  of  the  pelvis  and  the  upper  part  of  the  common  iliac 
vessels.  Without  relaxing  the  pressure  the  hand  is  made  to  roll  the 
abdominal  wall  over  the  parts  beneath,  when  any  irregularities,  if  pres- 
ent, can  be  readily  felt.  One  area  after  another  is  gone  over  in  this 
manner,  the  hand  still  firmly  applied,  and  sliding,  when  necessary,  over 
the  skin.  If  inspection  has  revealed  a  local  enlargement,  palpation  will 
confirm  it  and  give  an  idea  of  the  shape,  consistence,  and  character  of 
the  growth  or  other  cause.  When  a  tumor  is  found,  we  must  settle  the 
following  points  in  connection  with  it : 

1.  In  which  region  is  it  situated,  and  in  connection  with  what  organ  ? 

2.  Is  it  circumscribed  or  diffuse  ?  This  is  determined  by  passing  the 
fingers  around  it  as  far  as  possible,  and  between  it  and  the  abdominal 
bony  boundaries. 

3.  Is  it  solid  or  liquid  ?     In  tumors  of  dense  structure,  such  as  car- 


INJURIES  AND  DISEASES   OF  THE   DIGESTIVE  SYSTEM.       205 

cinoma,  a  feeling  of  hardness  can  be  recognized,  fluid  tumors  can  be 
detected  by  their  fluctuation,  but  between  these  two  extremes  are  many- 
grades  of  consistency  which  are  very  difficult  to  determine. 

4.  Is  it  movable  or  fixed  ?  The  hand  should  be  placed  upon  dif- 
ferent parts  of  the  tumor,  or  the  whole  tumor  grasped  by  the  hand  and 
its  mobility  tested.  If  freely  movable,  note  the  effect  of  change  of 
posture.  It  often  happens  that  the  patient  can  bring  the  growth  into 
prominence  by  lying  in  one  particular  position. 

5.  Is  its  surface  smooth  or  irregular,  and  is  its  consistence  uniform? 
The  points  of  the  fingers  moving  the  abdominal  wall  over  the  tumor 
will  detect  a  nodular  surface  if  it  be  present,  as  well  as  any  irregularity 
of  consistence,  such  as  would  result  from  the  formation  of  cysts  or 
abscesses  in  solid  growths. 

Palpation  bv  the  vagina  is  a  means  of  diagnosis  which  is  of  wide 
utility.  By  means  of  it  tumors  in  the  pelvis  can  be  felt  between  the 
finger  of  one  hand  in  the  vagina  and  the  other  hand  on  the  abdominal 
wall.  The  connection  of  the  tumor  with  the  uterus,  ovaries,  tubes,  or 
broad  ligament  can  be  settled  and  its  pedicle  or  base  localized. 

Palpation  by  the  rectum  is  valuable  in  the  diagnosis  of  tumors  low 
down  in  the  pelvis  or  involving  the  rectum  itself  It  was  recommended 
a  few  years  ago  as  an  aid  to  the  diagnosis  of  appendicitis,  but  I  am  not 
aware  that  it  has  ever  been  extensively  employed.  In  cases  of  great 
uncertainty,  as  in  supposed  stricture  of  the  rectum  high  up,  it  may  be 
necessary  to  introduce  the  whole  hand.  The  procedure  is  difficult  and 
not  free  from  danger.  I  have  had  recourse  to  it  but  once,  and  have 
never  met  with  any  one  who  advocated  it  as  a  valuable  method  of 
diagnosis. 

Percussion. — This  is  not  so  important  as  palpation,  of  which  it  may 
be  regarded  as  a  variety.  The  practised  diagnostication  will  bring  out 
distinct  sounds  where  the  tyro  finds  only  indefinite  thuds.  To  percuss 
to  the  best  advantage  we  should  imitate  the  action  of  the  piano.  A 
little  hammer  strikes  the  wires  with  a  sharp,  quick  stroke  and  rapidly 
rebounds,  leaving  the  string  to  give  out  by  its  vibration  a  full,  clear 
sound.  The  finger  of  the  left  hand  represents  the  piano-wire,  the  mid- 
dle finger  of  the  right  hand  represents  the  hammer ;  the  motion  should 
be  at  the  wrist,  and  the  percussing  finger  should  be  brought  dow^n  with 
a  sharp,  quick  tap,  and  made  to  fly  back  as  quickly  as  possible,  leaving 
the  vibration  of  the  part  percussed  to  give  out  a  clear,  unrestricted 
sound.  Applications  of  percussion  will  be  considered  under  the  special 
organs. 

Auscultation. — This  method  is  valuable  in  the  diagnosis  of  aneur- 
ysms, the  demonstration  of  placental  and  uterine  bruits,  the  friction- 
sound  of  peritonitis,  and  the  pulsation  of  the  fetal  heart. 

The  phonendoscope  is  an  instrument  of  considerable  value  in  exam- 
ination of  the  abdomen  and  thorax.  It  was  invented  by  Bianchi  of 
Florence,  aided  by  Bazzi,  the  celebrated  Italian  physician.  It  is  a 
modification  of  the  stethoscope,  the  sound  being  amplified  by  means 
of  a  resonator  similar  to  the  receiver  of  a  telephone.  Its  utility  as 
claimed  by  the  inventor  lies  in  the  following  directions:  i.  It  enables 
us  to  appreciate  normal  and  pathological  sounds  in  the  various  organs 
of  the  body — sounds  that  are  not  audible  by  any  other  means  of  aus- 


206  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

cultation ;  2.  By  it  may  be  determined  the  position,  thickness,  and 
relations  of  separate  organs.  It  is  thus  employed  :  The  instrument 
is  placed  upon  the  skin  over  the  organ  to  be  examined ;  the  index 
finger  of  the  right  hand  gently  strokes  the  skin  near  the  instru- 
ment, producing  a  distinct  vibratory  sound  which  varies  according 
to  the  size,  density,  and  thickness  of  the  organ  under  examination. 
The  stroking  is  continued  fartiier  and  farther  from  the  instrument 
until  a  change  in  the  sound  indicates  that  the  examining  finger  has 
passed  from  the  organ  under  examination  to  one  of  different 
conducting  power.  The  points  at  which  this  change  takes  place  can 
be  marked  upon  the  skin  and  the  limits  of  the  organ  accurately 
defined. 

In  examining  the  liver  the  instrument  should  be  successively  placed 
in  the  following  positions  :  beneath  the  ensiform  cartilage ;  in  the  right 
mammillary  line  in  the  seventh  intercostal  space ;  in  the  ninth  inter- 
costal space  over  the  mid-axillary  line.  Yo\  the  stomach,  place  the 
instrument  in  the  following  positions  :  the  seventh  intercostal  space 
in  the  left  mid-clavicular  line ;  on  the  linea  alba  near  the  left  free  edge 
of  the  ribs  and  below  the  greater  curvature.  In  this  examination  the 
cardia,  the  pylorus,  the  coils  of  the  intestine,  and  the  nature  of  their 
contents,  whether  fluid  or  gaseous,  can  be  determined. 

In  examining  the  colon,  place  the  instrument  in  the  right  iliac  fossa 
for  the  cecum,  and  beneath  the  free  border  of  the  ribs  in  the  anterior 
axillary  and  mid-axillary  lines  for  the  ascending  colon ;  for  the  trans- 
verse colon,  on  a  line  running  from  right  to  left  a  little  above  the 
umbilicus.  The  descending  colon  is  examined  by  placing  the  instru- 
ment beneath  the  left  free  border  of  the  ribs  and  also  in  the  left  iliac 
fossa.  In  all  cases  heavy  strokes  are  necessary  to  detect  fluids,  and 
light  strokes  to  detect  gases. 

When  a  tumor  is  to  be  examined,  the  instrument  should  be  placed 
over  the  center  of  the  growth. 

Exploratory  Puncture  and  Incision. — As  a  general  rule,  the 
exploring  needle  is  dangerous  in  the  abdominal  cavity,  and  at  this  day 
is  seldom  or  never  resorted  to  by  the  best  surgeons.  When  every 
other  method  of  diagnosis  has  been  carefully  and  exhaustively  tried, 
and  there  is  still  doubt  as  to  the  question  whether  a  given  growth  can 
be  safely  removed,  it  is  proper  to  make  an  abdominal  section.  In  the 
hands  of  a  skilful  operator  a  simple  incision,  to  admit  one  or  two 
fingers  and  explore  gently  the  abdominal  contents,  is  practically  devoid 
of  danger,  and  in  a  sense  safer  than  the  puncture  of  an  exploring 
needle.  On  the  other  hand,  there  is  nothing  so  mischievous  as  the 
idea  that  it  should  be  resorted  to  in  every  case  which  offers  obscure 
symptoms.  The  case  may  be  obscure  for  want  of  skill  and  experience 
in  the  examiner ;  to  subject  a  patient  to  an  operation  as  an  outlet  for 
ignorance  is  cruel  and  unwarrantable. 

When  such  an  incision  is  decided  upon,  every  preparation  should  be 
made  for  any  radical  operation  which  may  be  called  for.  The  incision 
should  at  first  be  made  only  sufificient  to  admit  one  or  two  fingers. 
Through  this  opening  a  search  can  be  made  of  the  whole  peritoneal 
cavity,  after  which  the  incision  can  be  extended  by  scissors  upward  or 
downward  as  required.     Unless  it  is  reasonably  certain  that  the  radical 


INJURIES  AND   DISEASES   OF   THE   DIGESTIVE   SYSTEM.        20J 

operation  can  be  successfully  carried  out,  the  parts  should  be  disturbed 
as  little  as  possible  and  the  opening  closed. 

Injuries  of  the  Abdomen. 

Contusions. — Owing  to  the  looseness  and  mobility  of  the  abdo- 
men, bruises  and  blows  may  produce  the  most  serious  results  without 
any  visible  marks  upon  the  skin.  Shock  is  always  pronounced,  and 
death  has  often  occurred  with  no  other  symptom,  post-mortem  ex- 
amination failing  to  reveal  any  structural  lesion.  Contusion  of  the 
abdominal  wall  may  cause  laceration  of  vessels  and  the  formation  of  a 
hematoma  in  the  sheath  of  the  muscles  or  the  areolar  tissue.  Hema- 
tomata  are  found  most  frequently  in  the  flanks  and  may  attain  an  enor- 
mous size.  If  they  remain  aseptic,  absorption  rapidly  takes  place,  and 
no  treatment  except  rest  is  necessary.  Should  they  continue  to  enlarge 
by  persistence  of  the  bleeding,  they  should  be  incised,  the  bleeding  ves- 
sel ligated,  or  the  cavity  packed  with  gauze.  When  sepsis  sets  in  incis- 
ion and  drainage  are  demanded.  A  blow  while  the  muscles  are  in  a 
state  of  rigid  contraction  may  cause  their  rupture,  leaving  a  weak  spot 
which  may  later  be  the  seat  of  a  ventral  hernia.  Rupture  of  muscle 
may  also  occur  during  severe  labor  or  in  the  violent  contractions  of 
tetanus.  Debilitating  diseases,  such  as  typhoid  fever,  weaken  the  mus- 
cles and  predispose  them  to  rupture.  The  symptoms  of  ruptured  mus- 
cle are  pain  and  tenderness.  When  the  rupture  is  extensive  a  depres- 
sion is  found  between  the  ruptured  muscular  structures.  The  treat- 
ment is  rest  and  soothing  applications.  It  may  be  practicable  in  some 
cases  to  cut  down  upon  the  injured  part  and  suture  the  divided  portions 
of  muscle.  It  sometimes  happens  that  septic  germs  find  an  entrance 
to  bruised  and  lacerated  tissues,  and  an  abscess  in  the  abdominal  wall 
is  the  result.  Such  an  abscess  is  surrounded  by  widespread  indura- 
tion, and  its  contents,  when  evacuated,  are  often  foul-smelling  like 
those  of  an  abscess  near  intestine.  The  parietal  peritoneum  is  occa- 
sionally ruptured,  and  the  result  may  be  peritonitis. 

Injury  to  the  Viscera  from  Abdominal  Contusions. — The  diagnosis 
of  these  internal  injuries  is  always  attended  with  difficulty.  Shock  is 
the  most  prominent  symptom.  The  patient  lies  in  a  state  of  collapse. 
If  this  increases,  we  may  assume  that  some  organ  has  been  ruptured 
or  that  hemorrhage  is  taking  place.  Hemorrhage  is  manifested  by 
increasing  pallor,  paleness  of  the  gums  and  lips,  yawning,  sighing, 
dilatation  of  the  pupils,  and  by  dulness  on  percussion  when  enough 
blood  has  been  poured  out  to  fill  a  part  of  the  abdominal  cavity.  When 
an  organ  is  ruptured  we  must  wait  for  secondary  effects.  The  bladder 
is  the  organ  most  easily  examined.  A  soft  catheter  can  be  introduced. 
If  clear  urine  escapes  and  in  considerable  quantity,  we  may  know  that 
there  is  no  rupture  ;  if,  on  the  other  hand,  a  small  amount  of  urine 
comes  away  and  it  is  stained  with  blood,  it  is  significant  of  rupture.  It 
is  seldom  that  an  empty  bladder  is  ruptured,  except  in  cases  where 
there  is  also  fracture  of  the  pelvis. 

The  Stomach. — Rupture  of  this  organ  may  be  suspected  when 
there  is  blood-stained  vomiting.  This,  however,  is  not  a  sign  of  great 
value,  for  it  may  be  due  to  bruising  of  mucous  membranes,  and,  besides, 


208  SIKGICAL    D/AGA'OSIS  AND    TREATMENT. 

if  the  laceration  in  the  stomach  be  extensive,  there  will  be  no  vomiting, 
for  the  contents  will  escape  into  the  peritoneal  cavity.  Pain  in  the  epi- 
j^astrium  is  significant  of  rupture  of  the  stomach  ;  pain  antl  tenderness 
around  or  below  the  umbilicus  point  to  the  intestine  as  the  seat  of  rup- 
ture. Escape  of  gases  into  the  abdomen  and  inflation  sufficient  to  give 
resonance  over  the  normal  position  of  the  liver  are  also  very  suggestive. 
A  distended  stomach  is  more  liable  to  suffer  rupture  than  one  compar- 
atively empty,  and  the  part  of  the  organ  generally  torn  is  that  near  the 
pylorus.  When  the  posterior  wall  of  the  stomach  is  ruptured  the  con- 
tents are  confined  by  the  lesser  omentum  and  an  abscess  may  result. 

The  intestine  is  most  easily  ruptured  at  the  point  which  is  most 
fixed — viz.  the  end  of  the  duodenum.  The  .symptoms  will  be  con- 
sidered under  Wounds  of  the  Abdomen. 

The  liver,  owing  to  its  size  and  weight,  is  liable  to  rupture.  The 
symptoms  are  those  produced  by  hemorrhage.  Fracture  of  ribs  over 
the  liver,  followed  by  collapse  and  other  signs  of  hemorrhage,  would  be 
very  strong  presumptive  evidence  of  rupture. 

Treatment. — Except  when  the  shock  is  slight  and  a  positive  diag- 
nosis can  be  made,  treatment  must  be  expectant.  Perfect  rest  must  be 
enjoined,  nourishment  must  be  given  by  small  enemata,  thirst  quenched 
by  small  pieces  of  ice,  and  stimulants  avoided  or  very  sparingly  em- 
ployed. Pain  may  be  removed  by  hypodermics  of  morphin.  The  prog- 
nosis is  much  more  grave  when  internal  organs  are  ruptured.  These 
are  usually  desperate  cases.  The  patient  tosses  from  side  to  side, 
finding  no  easy  posture  until  death  relieves  him,  or  the  collapse  deepens 
till  the  end  arrives.  Rupture  of  the  bladder  calls  for  immediate  ope- 
ration, as  does  also  any  form  of  internal  hemorrhage,  provided  the 
state  of  the  patient  warrants  such  interference. 

Wounds  of  the  Abdomen. 

Wounds  of  the  abdomen  very  naturally  divide  themselv^es  into  two 
classes:  (i)  Non-penetrating  wounds;  (2)  Penetrating  wounds. 

The  most  common  causes  of  abdominal  wounds  are  stabs  and  gun- 
shot injuries.  A  free  incised  wound  can  be  readily  examined  and  its 
depth  ascertained.  After  washing  out  the  clots  the  edges  can  be 
held  apart  and  the  divided  tissues  seen  or  felt.  When,  however,  the 
wound  is  a  small  penetrating  one,  as  a  stab  made  by  a  knife-thrust  or 
a  bullet,  the  question  of  penetration  is  not  so  easily  settled.  Here 
the  greatest  care  must  be  observed  lest  septic  matter  be  carried  into 
the  peritoneal  cavity.  The  skin  around  the  wound  and  the  wound 
itself  should  be  carefully  cleansed  and  disinfected.  A  director  should 
then  be  passed  into  the  wound  and  the  opening  enlarged  by  careful 
dissection  down  to  the  end  of  the  director.  Then  another  careful 
search  should  be  made,  and  if  the  director  can  be  made  to  pass  farther, 
the  dissection  should  be  continued  until  it  is  clearly  demonstrated 
whether  the  wound  ends  in  the  abdominal  wall  or  enters  the  peritoneum. 

A  non-pcnetratiiig  zuound  is  not  a  serious  matter.  The  parts  having 
first  been  carefully  disinfected,  sutures  of  silk  or  silkworm  gut  are  used 
to  obtain  perfect  apposition  of  the  parts,  as  in  celiotomy,  and  a  dress- 
ing applied.     The  danger  of  such  wounds  lies  in  the  fact  that  the 


INJURIES  AND  DISEASES   OF  THE   DIGESTIVE   SYSTEM.       2O9 

abdominal  wall  is  weakened  at  that  spot,  and  hernia  is  likely  to  follow. 
The  patient  should  lie  in  bed  for  at  least  three  weeks  to  give  the  parts 
time  to  become  firmly  united.  He  should  afterward  wear  an  abdominal 
belt  or  supporter,  and  should  avoid  severe  muscular  effort  for  many 
months. 

Penetrating  zvounds  are  further  divided  into  two  classes  :  {a)  those 
without  visceral  complications ;  {b)  those  in  which  one  or  more  of  the 
viscera  are  perforated.  When  the  external  wOund  is  large,  the  peri- 
toneum divided,  and  the  intestine  or  stomach  protruding,  the  case  is 
self-evident ;  and  all  that  remains  to  be  done  is  carefully  to  wash  the 
protruding  viscera  with  sterilized  water,  return  them  to  the  abdominal 
cavity,  and  close  the  wound.  The  escape  of  omentum  is  also  proof  of 
penetration.  In  cases  of  stab  or  bullet  wounds  with  small  tortuous 
tracks  it  is  usually  necessary  to  explore,  by  dissection,  in  the  manner 
already  described.  Penetrating  wounds  without  visceral  lesions  often 
do  well  when  treated  antiseptically.  The  peritoneum  should  be  sutured 
by  itself  by  means  of  catgut,  and  a  row  of  silkworm-gut  stitches  can 
be   used  to  close  the  remaining  structures. 

Symptoms  of  Visceral  "Wounds. — In  the  examination  of  a 
stab  or  gunshot  wound  of  the  abdomen  the  course  of  the  missile 
should  be  carefully  noted.  A  bullet  is  not  often  deflected  here,  as  in 
the  case  of  the  skull,  and  a  line  between  the  points  of  entrance  and 
exit  will  in  most  cases  indicate  the  region  transv^ersed  and  the  organs 
perforated.  It  may  be  set  down  as  a  rule  that  a  bullet  passing  through 
the  abdomen  from  side  to  side  perforates  the  intestine  in  from  four  to 
fourteen  places.  A  bullet  passing  antero-posteriorly  about  the  level  of 
the  umbilicus  gives  a  probability  of  no  visceral  perforation.  The  diffi- 
culty of  diagnosis  will  be  seen  as  we  take  up  the  symptoms  one  by  one. 

Shock. — A  non-penetrating  wound  of  the  abdominal  wall  may  be 
attended  with  profound  shock.  A  penetrating  wound  which  divides 
the  intestine  in  several  places  has  been  known  to  be  so  free  from  shock 
that  the  patient  has  walked  several  blocks  or  even  one  or  two  miles. 

Vomiting  may  be  a  marked  symptom  in  non-penetrating  wounds, 
so  that  it  is  no  proof  of  visceral  wound.  The  same  may  be  said  of  pain 
and  pallor  of  the  skin. 

Hemorrhage. — The  blood  that  gushes  from  the  parietal  wound 
counts  for  little,  as  it  is  the  flow  from  some  muscular  vessels  in  the 
wall.  Blood  from  a  wounded  internal  organ  is  poured  out  into  the 
peritoneal  cavity,  and  produces  constitutional  effects  which  are  difficult 
to  distinguish  from  shock.  We  must  be  guided  by  the  ordinary 
symptoms  of  hemorrhage,  such  as  pallor  of  the  face,  lips,  gums,  and 
conjunctiva,  yawning,  sighing,  fainting,  thirst,  and  jactitation.  Besides 
these,  a  careful  examination  should  be  made  by  percussion.  Blood 
collecting  in  the  abdominal  cavdty  soon  gives  dulness  in  the  flanks, 
which  changes  with  position,  as  happens  in  ascites. 

Escape  of  stomach  or  intestinal  contents  through  the  external 
wound  is  convincing  evidence,  but  this  happens  only  when  the  opening 
in  the  viscus  is  opposite  to  that  in  the  parietes  and  is  not  tortuous. 
When  the  contents  of  these  organs  escape,  they  do  so  into  the  abdom- 
inal cavity,  and  give  no  evidence  until  peritonitis  has  set  in. 

Emphysema  signifies  very  little^  for  it  may  be  produced  by  air, 
u 


2  10  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

which  has  entered  the  wound  from  without,  jTist  as  Hkely  as  by  gas 
which  has  escaped   from  the  alimentary  tract. 

Hydrogen-test. — To  Senn  we  are  indebted  for  a  very  valuable  aid 
in  the  diai,niosis  of  wounds  of  the  stomach  and  intestines.  Hydrogen 
is  a  liarmless  gas  which  can  be  injected  into  the  alimentary  canal  in 
any  quantit)%  producing  no  other  effects  than  distention  and  disinfection. 
The  gas  is  prepared  in  the  usual  way  from  pure  sulphuric  acid,  zinc, 
and  water,  and  collected  in  a  rubber  receiver  which  holds  not  less  than 
three  or  four  gallons.  The  tube  from  the  receiver  is  inserted  into  the 
rectum,  and,  while  an  assistant  holds  it  in  position  and  presses  the  anus 
about  it  to  prevent  escape,  the  gas  is  slowly  forced  into  the  bowel.  If 
the  ear  or  stethoscope  be  placed  over  the  position  of  the  ilio-cecal  valve, 
a  gurgling  sound  will  indicate  the  passage  of  the  gas  into  the  small 
intestine.  Should  there  be  a  perforation  of  the  intestine,  the  gas  escapes 
into  the  peritoneal  cavity,  and  thence  through  the  external  wound, 
where  it  can  be  detected  by  a  hissing  sound  or  may  even  be  ignited 
w^ith  a  match ;  or,  if  it  should  fail  to  escape  by  the  external  wound,  it 
will  fill  the  abdominal  cavity,  getting  between  the  liver  and  the  parietes, 
and  giving  a  resonant  note  in  the  normal  position  of  hepatic  dulness. 
When  this  test  is  to  be  applied  to  the  stomach,  a  soft  stomach-tube  is 
employed  and  the  gas  injected  as  before.  The  hydrogen-test  may  also 
be  found  valuable  in  deciding  the  question  of  penetration.  The  gas  is 
injected  into  the  wound  of  entrance.  If  there  is  no  penetration  of  the 
peritoneum,  the  hydrogen  will  pass  along  the  bullet-track  and  escape 
by  the  wound  of  exit.  Compress  the  wound  of  exit  and  increase  the 
gas-pressure,  and  emphysema  will  be  felt  along  the  course  of  the  bullet. 
If  there  is  penetration,  the  whole  abdomen  will  quickly  become  dis- 
tended and  tympanitic. 

Objections  to  the  use  of  hydrogen  are  the  dangers  of  over-dis- 
tention,  the  difficulty  of  returning  the  bowel  to  the  abdominal  cavity, 
and  the  fact  that  it  frequently  fails  as  a  test. 

Prognosis. — Wounds  of  the  abdomen  must  always  be  looked  upon 
as  of  the  utmost  seriousness.  In  considering  the  probability  of  recov- 
ery it  is  safe  to  estimate  the  three  divisions  as  follows  : 

1.  Non-penetrating  wounds,  prognosis  favorable.  Careful  anti- 
septic treatment  will  result  in  prompt  healing.  Accurate  apposition  by 
sutures  and  prolonged  rest  in  bed  will  guard  against  ventral  hernia. 

2.  Penetrating  wounds  without  visceral  injuiy,  while  more  dan- 
gerous than  the  preceding,  are  not  necessarily  fatal,  a  large  portion 
recovering  without  intra-abdominal  treatment,  provided  nothing  of  a 
septic  nature  has  entered  the  abdominal  cavity. 

3.  Penetrating  wounds  with  visceral  injury.  These  are  almost 
surely  fatal,  death  resulting  from  hemorrhage  or  peritonitis.  When  a 
large  vessel  is  wounded  or  when  there  is  profuse  parenchymatous 
hemorrhage,  as  from  the  liver  or  spleen,  death  follows  quickly.  A 
wound  of  the  stomach  or  intestine  allows  the  escape  of  the  contents  of 
the  injured  organ  into  the  peritoneal  cavity.  Peritonitis  speedily  fol- 
lows, and  death  takes  place  within  forty-eight  hours,  more  from  shock, 
perhaps,  than  from  sepsis.  There  is  a  bare  possibility  that  recovery 
may  follow  even  so  desperate  an  injury  as  this.  The  stomach  or  intes- 
tine, being  empty  at  the  time  of  the  accident,  may  at  its  injured  point 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE  SYSTEM.       211 

form  an  adhesion  with  a  neighboring  serous  surface,  and  the  general 
peritoneal  cavity  be  thus  protected.  This  contingency,  however,  is  too 
remote  to  enter  into  our  calculations  in  making  a  prognosis.  In  this 
third  class  of  cases  nothing  but  prompt  operative  interference  with  the 
view  of  arresting  hemorrhage  or  closing  wounds  in  the  viscera  will 
change  the  prognosis.  The  mortality  after  these  operations  may  be 
set  down  at  about  62  per  cent. 

Treatment. — A  non-penetrating  wound  must  not  be  treated  with 
indifference.  The  shock  is  often  severe,  and  frequently  it  is  so  more 
from  fricfht  than  from  the  extent  of  the  traumatism.  Soldiers  have 
been  picked  up  on  the  battle-field  in  a  state  of  profound  shock,  and 
have  quickly  rallied  and  gone  on  fighting  when  assured  by  the  surgeon 
that  the  supposed  fatal  injury  was  only  an  abrasion  of  the  skin.  The 
treatment  of  a  non-penetrating  wound  consists  in  disinfecting  the  wound 
and  surrounding  parts.  None  but  perfectly  aseptic  fingers  and  instru- 
ments should  be  used  in  exploring  the  wound.  Care  must  be  taken  in 
application  of  sutures  to  restore  the  abdominal  wall  to  its  original 
strength  and  thus  prevent  ventral  hernia.  When  drainage  is  called 
for,  a  few  strands  of  catgut  are  better  than  non-absorbent  drainage- 
tubes. 

In  penetrating  wounds,  when  the  omentum  or  viscera  protrude, 
these  structures  must  be  examined  for  injury.  They  should  then  be 
carefully  washed  with  sterilized  water  and  returned  to  their  normal 
position.  The  peritoneum  should  be  closed  by  a  continuous  catgut 
suture  and  the  abdominal  wall  by  silkworm  gut  or  strong  silk.  When 
the  wound  is  of  considerable  size,  the  greatest  care  should  be  taken  to 
guard  against  a  subsequent  hernia  ;  this  is  best  averted  by  keeping  the 
patient  in  bed  for  three  or  four  weeks,  and  by  having  him  wear  an 
abdominal  belt  or  support  for  several  months  afterward. 

Penetrating  wounds  with  visceral  injury  either  forbid  interference  or 
demand  the  promptest  action.  If  the  patient  is  evidently  sinking,  and 
his  general  condition  such  that  he  cannot  endui-e  a  prolonged  operation, 
he  would  better  be  left  alone. 

Two  conditions  demand  operation  :  (i)  Profuse  internal  hemorrhage  ; 
(2)  Perforation  of  stomach  or  intestine  large  enough  to  allow  the  escape 
of  its  contents. 

No  rules  can  be  laid  down  as  a  guide  in  such  cases  ;  the  condition 
of  the  patient  and  the  special  indications  must  be  left  to  the  surgeon's 
individual  judgment.  When  there  is  profound  shock  it  is  necessary  to 
employ  suitable  remedies  and  wait  for  reaction.  Symptoms  of  peri- 
tonitis should  not  be  waited  for.  When  they  appear  the  case  is  almost 
beyond  hope.  Adhesions  by  this  time  will  have  taken  place  and  per- 
forations cannot  be  found.  The  perplexing  point  to  the  surgeon  is 
this  :  There  is  evidently  perforation,  but  the  patient's  condition  does  not 
appear  serious  enough  to  demand  operation.  On  the  other  hand,  if  he 
waits  for  these  serious  symptoms  to  come  on,  the  case  will  then  be 
beyond  hope.  It  is  unquestionable  that  the  earlier  an  operation  can  be 
resorted  to  the  better  will  be  the  result.  Coley  has  shown  that  of  39 
cases  operated  upon  within  twelve  hours,  18  recovered.  Of  22  ope- 
rated upon  after  twelve  hours,  only  5  recovered. 

Operation. — Iiistnniioits   Required. — Besides    the    ordinar}^  instru- 


212  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

mcnts  required  for  an  abdominal  section,  there  should  be  at  hand  the 
follo\vin<^ : 

Four  intestinal  clamps ;  ten  round  milliner's  needles  for  enteror- 
rhaphy  threaded  with  fine  silk  ;  stout  catgut  for  suturing  wounds  in  the 
solid  viscera. 

Preparation  of  tJic  Paticiit. — For  the  relief  of  shock  and  for  pro- 
longing anesthesia  a  hypodermic  injection  of  ]  grain  of  morphin  and 
Toif  ^'"'^iii  of  atropia  should  be  given.  If  there  is  indication  that  the 
stomach  is  the  seat  of  injury,  this  organ  should  be  emptied  by  the 
stomach-tube  and  washed  out  with  w'arm  sterilized  water.  The  bowels 
can  be  emptied  by  an  enema  containing  a  little  salt.  Some  advocate 
the  use  of  whiskey  as  a  stimulating  enema.  The  whole  abdomen 
should  be  thoroughly  washed  and  disinfected  and  the  wound  carefully 
cleansed. 

The  Ineision. — Except  when  the  position  of  the  external  wound 
would  strongly  indicate  to  the  contrary,  a  median  incision  is  to  be 
chosen.  It  gives  better  opportunities  for  examining  intestines  and 
stomach  and  a  broader  field  in  which  to  search  for  bleeding  vessels. 
No  rule,  however,  can  hold  good  here.  The  course  of  a  bullet  or  the 
direction  of  a  stab  wound  will  afford  a  pretty  safe  indication  of  the 
organs  injured,  and  these  must  be  reached  by  the  incision  which  best 
exposes  them. 

Arrest  of  Hcniorrliage. — When  hemorrhage  is  the  prominent  symp- 
tom, a  free  incision  is  necessary  to  bring  the  bleeding  points  into  view. 
If  one  of  the  solid  organs  be  wounded,  the  character  of  the  bleeding 
will  be  parenchymatous.  A  wound  in  the  liver  should  be  treated  with 
a  suture  of  stout  catgut  or  packed  with  a  strip  of  iodoform  gauze,  the 
end  of  which  is  left  projecting  from  the  parietal  wound.  A  profusely 
bleeding  kidney  may  require  nephrectomy ;  a  wounded  spleen  may 
bleed  so  profusely  that  nothing  but  splenectomy  will  suffice.  When 
there  is  a  copious  flow  of  blood,  which  accumulates  as  fast  as  it  can  be 
sponged  out,  the  aorta  should  be  compressed  by  an  assistant.  This 
requires  a  larger  incision  than  ordinary,  to  allow  the  hand  of  the  assist- 
ant to  reach  the  vessel  just  below  the  diaphragm.  Compression  of 
the  aorta  in  this  manner  controls  the  flow  of  blood  from  all  the 
abdominal  organs,  and  gives  the  operator  time  to  find  the  bleeding 
points.  The  vessels  of  the  mesentery  are  best  controlled  by  ligature 
en  masse. 

Perforations. — Having  checked  all  hemorrhage,  a  rapid  search  must 
be  made  for  perforation  of  the  stomach  or  intestines.  As  soon  as  an 
opening  is  found  it  should  be  immediately  closed  with  pressure-forceps, 
and  held  in  the  angle  of  the  wound  by  an  assistant  while  the  operator 
continues  his  search.  Every  opening,  as  soon  as  discovered,  is  clamped 
in  a  similar  manner  until  all  are  secured.  Greig  Smith  advises  the  use 
of  abdominal  irrigation  during  the  whole  of  the  time  that  closure  of 
visceral  wounds  is  being  carried  out.  It  cleanses  the  abdomen  and 
thus  saves  time,  and  if  water  at  a  temperature  of  i  io°  F.  be  employed, 
it  W'ill  prove  an  excellent  remedy  for  shock. 

Suturing  the  Perforations. — One  by  one  the  wounds  are  closed. 
Sponges  are  arranged  around  the  abdominal  opening  and  the  intestine 
or  stomach  brought  out.     Lembert  sutures  are  the  most  suitable.    The 


INJURIES  AND  DISEASES   OF   THE  DIGESTIVE   SYSTEM.       21 3 

lacerated  edges  of  the  intestinal  wounds  are  turned  inward  and  the 
serous  surfaces  brought  together.  Four  to  six  sutures  should  be 
applied  to  every  inch  of  incision,  and  the  best  material  for  this  purpose 


Fig.  icx>. — Czemy-Lembert  suture. 


Fig.  ioi. — Jobert's  suture  tor  partial  division  of 
gut :  a,  serous  ;  b,  muscular  ;  c,  mucous  coat. 


is  fine  silk.  Wounds  in  the  intestine  should  be  sutured  transversely  to 
prevent  constriction  of  the  lumen ;  in  the  stomach  the  direction  should 
be  in  the  long  axis  of  the  organ.     When  the  bowel  is  wounded  near 


Fig.  I02. — Lembert  continuous  stitch. 


its  mesenteric  border  gangrene  is  apt  to  result,  as  there  is  a  danger  of  the 
blood-supply  being  cut  off  from  that  part  of  the  intestine.  This  may 
necessitate  the  removal  of  a  portion  of  the  bowel.     A  section  of  the 


b-=^. 


Fig.  103. — Jobert's  suture  for  complete  trans- 
verse division  of  gut :  a,  serous  ;  b,  muscular ;  c, 
mucous  coat. 


Fig.  104. — The  suture  tightened, 
showing  Lembert's  suture  introduced 
to  give  additional  security. 


bowel  will  also  require  removal  when  there  is  a  double  perforation  or  a 
laceration  so  large  as  to  destroy  a  great  part  of  the  circumference  of 
the  tube.  When  this  has  to  be  done  the  mesentery  attached  to  the 
condemned  part  of  intestine  is  tied  off  in  sections  with  fine  silk  before 


214  SURGICAL  DIAGNOSIS  AND    TREATMENT. 

removal  of  the  bowel.  When  the  intestine  is  simply  contused,  the 
injured  portion  may  be  turned  inward  and  sound  serous  surfaces 
brou^^ht  together  with  Lembert  sutures;  then,  should  sloughing  take 
place,  the  necrotic  portion  will  fall  within  the  bowel.  Each  wound 
after  having  been  sutured  is  carefully  washed,  and,  if  possible,  rendered 
more  secure  by  an  omental  graft.  This  is  accomplished  by  taking  an 
adjacent  portion  of  the  omentum  and  laying  it  upon  the  contused  or 
sutured  surface  of  bowel,  retaining  it  in  position  by  two  catgut  sutures 
loosely  tied.  Adhesions  will  be  hastened  if  the  opposing  surfaces  are 
first  scratched  by  the  point  of  a  needle. 

Irrigation  of  the  Abdominal  Cavity. — Having  closed  every  perfora- 
tion and  stopped  all  bleeding  points,  the  cavity  of  the  abdomen  is  next 
thoroughly  washed  out  with  warm  water.  If  this  has  been  kept  up 
during  the  preceding  steps  of  the  operation,  very  little  time  will  be 
required  for  a  final  flushing.  In  any  case  a  full  stream  of  warm  steril- 
ized water  or  mild  antiseptic  solution  is  allowed  to  flow  into  the  cavity, 
while  the  bowels  are  moved  gently  about  to  allow  the  fluid  to  reach 
every  part,  and  this  is  kept  up  until  the  water  returns  as  clear  as  it  went 
in.     The  cavity  is  then  dried  with  warm  sponges. 

Drainage  is  necessary,  as  a  rule,  when  there  has  been  gross  infection 
by  the  extravasation  of  visceral  contents  or  when  there  is  a  continu- 
ance of  parenchymatous  hemorrhage.  The  parietal  wound  is  closed 
by  means  of  silkworm-gut  sutures,  as  in  any  abdominal  section. 

After-treatment. — When  the  intestine  has  been  the  seat  of  operation 
perfect  rest  of  the  organs,  even  from  their  own  peristaltic  action,  is 
necessary.  The  stomach  and  upper  part  of  the  small  intestine  are 
rested  by  taking  no  food  into  the  mouth  for  three  or  four  days,  and 
then  only  liquids,  such  as  peptonized  milk,  diluted  peptons,  or  jellies. 
Opiates  are  recommended  for  the  purpose  of  restraining  peristalsis.  It 
is  doubtful  whether  this  is  a  wise  procedure.  If  the  dose  of  morphin 
and  atropia  be  given  just  before  the  operation,  as  already  advised,  its 
effect  will  be  to  keep  the  intestines  quiet  for  some  time.  Adhesions  of 
serous  surfaces  take  place  rapidly,  and,  if  union  is  to  occur  at  all,  it 
will  be  pretty  firm  at  the  end  of  twenty-four  hours  or  even  in  less  time. 
The  arrest  of  peristalsis  is  not  necessary  beyond  this,  and  opiates  are 
certainly  contraindicated  as  interfering  with  the  absorbent  action  of  the 
peritoneum.  When  a  drainage-tube  is  employed  care  must  be  taken  to 
keep  the  fluid  drawn  out  at  frequent  intervals  by  means  of  an  exhaust- 
ing syringe.  Should  the  temperature  rise  and  other  symptoms  of  sepsis 
set  in,  it  is  probably  because  the  peritoneal  cavity  is  shut  off  around 
the  drainage-tube  and  a  collection  of  pus  is  taking  place.  The  best 
thing  to  do  in  this  case  is  to  remove  the  drainage-tube,  insert  one 
finger  into  the  opening,  carefully  break  up  the  newly-formed  adhesions, 
and  wash  out  the  collection  of  pus  by  irrigation.  I  am  confident  of 
having  saved  at  least  two  cases  of  general  peritoneal  sepsis  in  this 
way.  6 

When  all  goes  well,  liquid  food  can  be  given  by  the  stomach  at 
about  the  end  of  the  third  day,  and  solid  food  in  an  easily  digested 
form  at  about  the  end  of  a  week.  The  parietal  wound  is  treated  as  in 
other  abdominal  sections,  care  being  taken  to  allow  a  good  firm  cicatrix 
to   form  before  the  patient  is  allowed  to  go  about,  and  an  abdominal 


INJURIES  AND   DISEASES   OF   THE   DIGESTIVE   SYSTEM.        21 5 

support  should  be  worn  for  sev^eral  months  with  the  view  of  preventing 
ventral  hernia. 

III.    EXAMINATION   OF  THE   STOMACH. 

Inspection. — Valuable  data  in  the  diagnosis  of  diseased  conditions 
of  the  stomach  can  be  obtained  from  the  amount  of  distention  of  the 
organ.  A  flat,  collapsed  condition  at  the  epigastrium  is  sometimes 
seen  when  there  is  obstruction  at  the  cardiac  orifice ;  bulging  and  tume- 
faction occur  when  the  pylorus  is  the  seat  of  stricture.  Tumors  in  the 
anterior  wall  or  at  either  orifice  may  cause  a  bulging  at  the  epigastrium. 
Peristaltic  movements  may  be  observed  in  certain  cases.  Normal 
waves  begin  at  the  cardiac  end  and  extend  to  the  pylorus.  Anti- 
peristaltic waves  take  the  opposite  course,  and  are  an  indication  of 
stricture  at  the  pylorus.  These  movements  are  increased  by  the  use  of 
the  faradic  current,  or  by  the  application  of  the  ether  spray,  or  by 
striking  the  abdomen  with  a  wet  towel. 

Palpation. — The  first  thing  to  be  sought  for  is  localized  pain, 
which  can  be  readily  detected  by  making  gentle  pressure  with  the 
fingers  over  the  region.  Any  inequalities  in  the  abdominal  wall  should 
be  carefully  noted  and  a  tumor  sought  for.  Sometimes  a  growth  is 
lower  down  than  the  normal  position  of  the  stomach,  its  own  weight 
causing  it  to  sink  to  a  lower  level  in  the  abdominal  cavity.  Dilatation 
of  the  stomach  may  force  a  pyloric  tumor  downward.  In  its  early 
stages  a  tumor  of  the  pylorus  is  freely  movable,  later  it  becomes  fixed. 

Percussion. — The  whole  of  the  stomach  cannot  be  outlined  by 
percussion.  On  the  right  side  the  liver  overlaps  a  portion  of  the  organ, 
while  the  lung  encroaches  upon  it  on  the  left.  The  lower  limit  is 
about  midway  between  the  ensiform  cartilage  and  the  umbilicus,  and 
passes  in  a  curve  to  the  lower  border  of  the  end  of  the  tenth  rib.  In 
percussing  the  stomach  it  is  convenient  to  begin  with  the  right  hypo- 
chondriac region.  From  liver  dulness  we  come  abruptly  upon  the 
tympanitic  stomach,  and  find  no  difficulty  in  determining  where  one 
begins  and  the  other  ends.  On  the  left  side  the  pulmonary  resonance 
is  easily  distinguished  from  the  tympanitic  note  over  the  stomach.  At 
the  lower  border  considerable  difficulty  may  be  met  with.  The  stomach 
here  is  bounded  by  the  colon,  and  it  may  happen  that  the  note  in  both 
has  the  same  pitch.  As  a  rule,  however,  the  note  over  the  stomach  is 
more  tympanitic,  louder  in  tone,  and  lower  in  pitch  than  that  over' the 
colon,  so  that  in  the  majority  of  cases  the  lower  border  of  the  stomach 
can  be  accurately  mapped  out.  Allowances  must  always  be  made  for 
the  nature  and  amount  of  the  stomach-contents.  When  the  organ  is 
full  the  note  is  dull  and  muffled,  and  the  area  of  dulness  corresponds 
with  the  degree  of  gastric  distention.  Change  of  position  will  be  found 
to  change  the  percussion-note.  Gas  rises  to  the  surface,  giving  a 
tympanitic  resonance,  while  fluid  gravitates  to  the  most  dependent  parts 
and  affords  a  dull  note. 

As  an  aid  in  ascertaining  its  exact  size,  Piorry  suggested  filling  the 
stomach  with  water.  About  a  liter  is  given  the  patient  to  drink,  and 
he  is  examined  when  standing.  The  stomach  thus  distended  gives  a 
dull  note,  in  contrast  to  the  tympanitic  sound  produced  when  the  colon 
is  percussed. 


2l6  SUKU/CAI.    D/AGiVOS/S  AND    TREATMENT. 

The  metliod  of  Dchio  consists  in  ^ivinj^  the  water  in  fractional 
quantities.  The  hter  of  water  is  divided  into  four  parts,  each  part 
being  taken  separately  at  short  intervals,  and  an  examination  made 
after  each  dose.  The  area  of  dulness  is  marked  upon  the  abdomen 
after  each  examination.  This  method  is  valuable  in  detecting  dilatation 
of  the  stomach  and  atony  of  the  organ.  When  the  area  of  dulness 
descends  below  the  umbilicus,  it  indicates  dilatation.  When  the  dull 
area  descends  rapidly  after  each  addition  of  water,  atony  of  the  gastric 
muscle  may  be  diagnosticated.  The  lower  limit  of  a  healthy  stomach 
never  descends  below  the  umbilicus. 

Frielich  was  in  the  habit  of  distending  the  stomach  with  carbonic- 
acid  gas.  The  patient  took  2  grams  of  sodium  bicarbonate  dissolved 
in  water,  and  then  an  equal  quantity  of  water  containing  2  grams  of 
tartaric  acid.  A  rapid  disengagement  of  carbonic  acid  takes  place  in 
the  stomach,  which  so  distends  it  that  the  contour  of  the  organ  may 
be  seen  through  the  abdominal  wall.  This  method  is  not  free  from 
danger,  as  the  distention  may  be  excessive  and  is  always  beyond  con- 
trol. Sometimes  the  quantity  of  gas  is  not  sufficient  to  distend  the 
stomach. 

The  method  of  Runeberg  is  the  most  satisfactory.  It  consists  in 
distending  the  stomach  with  air  by  means  of  a  tube  to  which  is 
attached  a  rubber  bulb.  The  quantity  of  air  is  thus  under  direct 
control,  and  the  stomach  is  examined  in  different  degrees  of  dis- 
tention. At  the  end  of  the  examination  the  air  can  be  withdrawn 
through  the  tube.  All  these  examinations  are  greatly  aided  by  the 
use  of  the  phonendoscope.    (See  ^Examination  of  the  Abdomen.) 

The  stomach  itself  is  movable,  rising  beneath  the  chest-wall  when 
pushed  upward  by  abdominal  distention,  and  sinking  lower  into  the 
peritoneal  cavity  when  anything  depresses  the  diaphragm.  An  enlarged 
liver  encroaches  upon  the  stomach  from  the  right,  and  an  enlarged 
spleen  from  the  left.  Contraction  of  the  liver,  on  the  other  hand, 
increases  the  area  of  stomach-resonance. 

Auscultation  is  of  little  value  in  the  diagnosis  of  stomach-diseases. 
Splashing,  gurgling,  and  metallic  sounds  may  be  produced  by  rapid 
voluntary  movements  of  the  diaphragm,  by  the  natural  movements  of 
the  stomach  itself,  by  moving  the  patient  quickly  from  side  to  side,  or 
by  pressing  upon  the  stomach  and  suddenly  relaxing  the  pressure. 

If  you  direct  the  patient  to  swallow  fluid  and  place  your  stethoscope 
over  the  esophagus,  two  sounds  are  heard  :  the  first  is  a  spurting  sound, 
and  is  due  to  the  passage  of  the  liquid  along  the  esophagus ;  the 
second  sound  is  produced  by  the  escape  of  the  fluid  from  the  esophagus 
into  the  stomach.  In  healthy  conditions  the  interval  between  these  two 
sounds  should  not  exceed  ten  seconds ;  in  cases  of  constriction  of  the 
cardiac  orifice  the  interval  may  be  extended  to  a  minute  or  more. 

Chemical  exaniiiiatioii  of  stoinach-conicnts  (see  Cancer  of  the 
Stomach). 

Injuries   and    Diseases   of  the  Stomach. 

The  chest-wall  above  and  the  thick  muscular  abdominal  wall  in 
front  protect  the  stomach  from  external  injury.  A  sharp  instrument 
can  readily  pierce  the  organ,  but  a  blow  from  a  blunt  object  throws  the 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE   SYSTEM.        21/ 

abdominal  muscles  into  strong  contraction,  and  the  stomach  readily 
yields  before  the  pressure  or  slips  from  under  the  force.  If,  however, 
the  stomach  contain  a  considerable  quantity  of  food  or  be  distended 
with  gas,  rupture  may  take  place.  One  or  more  coats  may  give  way 
or  the  whole  thickness  of  the  gastric  wall  may  be  lacerated,  permitting 
the  contents  to  flow  into  the  peritoneal  cavity,  and  producing  death  by 
peritonitis  within  forty-eight  hours.  When  one  coat  only  is  ruptured, 
it  is  usually  the  peritoneal,  that  being  less  elastic  than  either  the 
muscular  or  mucous  covering. 

Syniptoiiis  of  Rupture. — When  only  the  peritoneal  coat  is  ruptured, 
the  symptoms  are  pain  and  localized  peritonitis.  The  torn  perito- 
neum almost  immediately  becomes  adherent  to  the  peritoneal  sur- 
face of  some  other  organ,  adhesive  inflammation  throws  out  a  bar- 
rier against  further  mischief,  and  the  process  of  repair  rapidly  takes 
place.  A  localized  peritonitis,  following  a  blow  or  kick  over  the 
stomach,  is  very  suggestive  of  this  form  of  rupture,  and  such  a  condi- 
tion should  be  treated  by  placing  the  organ  at  perfect  rest  by  with- 
holding food  for  several  days  and  by  nourishing  the  patient  with 
nutrient  enemata. 

When  the  mucous  or  muscular  coat  is  ruptured  hemorrhage  into 
the  stomach  is  the  prominent  symptom.  Vomiting  of  blood  must 
therefore  be  regarded  as  very  important  when  it  follows  a  traumatism  in 
the  epigastric  region.  Rupture  of  the  whole  thickness  of  the  stomach- 
wall  is  followed  by  the  most  serious  symptoms.  Shock  is  severe  and  pain 
is  intense.  The  contents  of  the  stomach  are  poured  out  into  the  abdomi- 
nal cavity,  and  the  symptoms  of  general  peritonitis  rapidly  appear. 
Some  patients  never  rally  from  the  first  shock  ;  others  die  of  peri- 
tonitis in  about    two  days. 

Tvcatinoit. — If  ever  there  is  a  condition  requiring  prompt  and 
immediate  heroic  measures,  it  is  here.  Once  the  diagnosis  of  complete 
rupture  has  been  made,  there  is  not  a  moment  to  be  lost.  A  free 
incision,  beginning  at  the  ensiform  cartilage  and  extending  to  the 
umbilicus,  is  required.  The  rent  should  then  be  sought  and  brought 
to  the  surface.  If  situated  at  the  posterior  wall  of  the  stomach,  the 
gastro-colic  omentum  must  be  divided  before  the  laceration  can  be 
reached.  Having  brought  the  edges  of  the  rent  to  the  abdominal 
wound,  the  stomach  should  be  washed  out  with  sterilized  water,  after 
which  it  should  be  sutured  by  two  rows  of  silk  stitches,  the  one  passing 
through  the  muscular  and  mucous  coats  and  cut  short.  The  second 
row  takes  the  peritoneum  and  passes  into  the  muscular  coat,  so  that  it 
buries  the  first  row  and  brings  the  peritoneal  surfaces  together.  Any 
stomach-contents  found  in  the  peritoneal  cavity  should  be  mopped  out 
with  sponges,  and,  if  there  be  general  contamination,  the  whole  should 
be  flushed  with  sterilized  water  or  Thiersch's  solution.  Drainage  is 
necessary  when  the  contamination  has  been  extensive  or  long  con- 
tinued. The  after-treatment  requires  stimulation  by  hypodermics  of 
strychnia  or  brandy  and  perfect  rest  to  the  stomach. 

Foreign  Bodies  in  the  Stomach. — Children  frequently  swallow 
coins  and  other  small  bodies  with  impunity.  I  had  until  recently  in  my 
possession  a  pocket-knife  blade,  one  and  three-quarter  inches  in  length, 
which  passed    through  the    alimentary  canal  of  a  four-year-old  boy. 


2l8  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

The  blade  was  somewhat  eroded,  but  the  boy  was  none  the  worse  for 
the  mishap.  Bodies  which  pass  through  the  pharynx  and  esophagus 
are  pretty  sure  to  pass  through  the  remainder  of  the  digestive  tract, 
particularly  if  the  friends  abstain  from  the  common  practice  of  giving 
purgatives.  Food  should  be  allowed  which  ensures  the  formation  of 
bulky  stools,  and  for  this  purpose  an  exclusive  diet  of  mashed  potatoes 
and  milk  answers  admirably. 

Mechanical  Fixation  of  the  Stomach. — When  from  injury, 
disease,  or  as  a  sequel  of  celiotomy  the  stomach  becomes  adherent  to 
the  parietes,  considerable  suffering  and  inconvenience  may  result.  Such 
cases  are  often  set  down  as  gastric  neurosis.  Landerer  of  Leipzig  has 
reported  three  cases  of  intense  gastralgia  attended  with  vomiting  and 
tenderness  at  the  epigastrium.  In  the  first  case  a  band  of  adhesion 
was  found  between  the  parietal  peritoneum  and  the  stomach,  the 
removal  of  which  was  followed  by  perfect  recovery.  In  the  second 
case  the  stomach  was  found  adherent  to  the  left  lobe  of  the  liver, 
and  recovery  followed  the  breaking  up  of  the  adhesion.  The  third 
was  produced  by  a  small  umbilical  hernia,  to  which  a  section  of  the 
stomach  the  size  of  a  small  apple  was  firmly  adherent.  All  the 
symptoms  subsided  after  freeing  the  stomach  and  stitching  the  her- 
nial ring.^ 

A  case  is  reported  by  Dr.  Davis  of  Omaha  in  which  persistent 
attacks  of  vomiting,  severe  gastric  pain,  nervousness,  cardiac  depres- 
sion, and  high  temperature  were  finally  traced  to  a  small  hernia  in  the 
linea  alba,  to  the  sac  of  which  was  attached  a  band  of  omentum. 
Tracing  the  omentum  inward,  it  assumed  the  form  of  a  band  the  end 
of  which  was  adherent  to  the  greater  curvature  of  the  stomach. 
Division  of  the  band  and  radical  treatment  of  the  hernia  effected  a  com- 
plete cure. 

Landerer  points  out  a  very  simple  and  reasonable  symptom  of  this 
condition.  //  is  the  production  of  pain  in  the  stomach  from  movement  of 
the  visciis.  Washing  out  the  stomach  and  movements  of  the  body 
which  cause  a  dragging  of  the  stomach  at  the  adherent  point  are 
followed  by  long-continued  pain. 

Ulcer. — Ulcer  of  the  stomach  until  a  recent  date  was  regarded  as 
entirely  within  the  domain  of  medicine.  At  present  it  may  be  looked 
upon  as  an  outpost  on  the  frontier  of  surgery.  Perforating  ulcer  has 
long  been  recognized.  Its  starting-point  is  in  a  small  arterial  branch 
which  becomes  occluded,  and  thus  the  supply  of  blood  is  cut  off  from  a 
portion  of  the  stomach-wall.  Necrosis  of  the  area  thus  cut  off  follows. 
The  necrosed  part  takes  the  form  of  a  cone  with  its  apex  toward  the 
peritoneal  and  its  base  at  the  mucous  coat.  The  destruction  of  tissue 
is  hastened  by  the  action  of  the  gastric  juice,  and  the  slough,  coming 
away  en  masse  or  by  molecular  death,  leaves  an  ulcer  which  the  term 
"  perforating "  aptly  describes.  Not  infrequently  severe  hemorrhage 
follows,  and  by  repeated  losses  of  blood  the  patient  may  be  brought  to 
a  state  of  great  anemia  and  even  unto  death  itself 

Symptoms. — Two  leading  symptoms  attract  our  attention  in  gastric 
ulcer — a  fixed  pain  with  localized  tenderness  on  pressure,  and  vomiting 
soon  after  taking  food.     Surgically,  we  are  interested  in  ulcer  from  the 

'  Annual  of  Universal  Medical  Sciences,  1894. 


INJURIES  AND   DISEASES   OF   THE   DIGESTIVE   SYSTEM        2I9 

fact  that  perforation  is  a  not  infrequent  termination.     Haslan  of  Bir- 
mingham, England,  describes  perforating  ulcers  under  three  classes : 

1.  Where  no  adhesions  have  formed  around  the  base  of  the  ulcef, 
and  the  stomach-contents  pass  at  once  and  freely  into  the  peritoneal 
cavity.  The  location  of  ulcers  of  this  class  is  usually  on  the  anterior 
surface  of  the  stomach  The  symptoms  here  are  sudden  and  severe, 
almost  identical  with  those  following  rupture  of  the  stomach.  Shock 
is  more  or  less  marked ;  there  are  abdominal  pain  and  tenderness  on 
pressure,  with  the  train  of  symptoms  which  make  up  the  sum-total 
of  general  peritonitis.  The  duration  of  life  after  perforation  occurring 
in  this  manner  ranges  from  seven  hours  to  five  days,  the  majority  dying 
within  twenty-four  hours. 

2.  Where  adhesions  around  the  base  of  the  ulcer  have  fixed  the 
stomach  to  some  adjacent  organ,  the  leakage  causing  a  localized  peri- 
tonitis. Suppuration  follows  perforation  of  this  class,  but  the  collec- 
tions of  pus  are  shut  off  from  the  general  peritoneal  cavity.  The  diag- 
nosis here  must  rest  upon  the  history  of  gastric  ulcer,  the  occurrence 
of  localized  peritonitis,  followed  by  induration,  and  such  other  signs  as 
indicate  a  collection  of  pus. 

3.  Cases  in  which  adhesions  have  formed  between  the  stomach  and 
some  hollow  viscus  or  serous  cavity,  into  which  an  opening  from  the 
stomach  becomes  established.  In  this  way  the  stomach-contents  have 
found  their  way  into  the  colon,  the  pericardium,  or  the  pleura. 

Treatment. — In  the  first  class  of  cases  clinical  experience  teaches  us 
that  there  is  only  one  termination — death — and  that  the  fatal  issue 
occurs  in  the  majority  of  cases  within  twenty-four  hours.  Any  attempt, 
therefore,  which  gives  a  hope  of  placing  the  patient  in  a  more  favorable 
position  is  justifiable.  The  operation  recommended  consists  in  making 
an  incision  above  the  umbilicus  a  little  to  the  left  of  the  middle  line,  in 
order  to  avoid  the  falciform  ligament.  The  patient,  being  the  subject  of 
shock,  must  be  treated  for  this  condition  by  hypodermics  of  str}xhnin 
and  by  surrounding  him  with  hot  bottles.  The  most  common  seat  of 
ulcer  is  found  to  be  at  or  near  the  lesser  curvature.  As  a  rule,  the 
portion  of  the  stomach  which  presents  at  the  parietal  wound  in  this 
operation  is  the  greater  curvature  or  the  part  a  little  above  it.  The 
finger  should  be  made  to  pass  over  the  surface  of  the  stomach  upward 
and  backward  in  search  of  the  perforation,  and,  as  already  stated,  it 
will  be  found  at  or  near  the  lesser  curvature.  The  succeeding  steps 
of  the  operation  are  identical  with  those  in  the  operation  for  rupture 
of  the  stomach. 

Gastric  Fistula. — In  the  rare  cases  in  which  adhesions  form 
between  the  stomach  and  the  abdominal  wall  and  shut  off  the  peri- 
toneal cavity  before  the  occurrence  of  perforation  a  gastric  fistula  may 
be  the  result.  A  similar  condition  may  arise  after  a  wound  of  the 
abdominal  wall  which  extends  into  the  stomach,  or  the  fistula  may  be 
intentionally  made  for  the  relief  of  a  constriction  at  the  lower  end  of 
the  esophagus  or  at  one  or  other  of  the  orifices  of  the  stomach. 

Treatment. — The  operation  for  the  closure  of  the  gastric  fistula  will 
vary  according  to  the  length  and  connections  of  the  fistulous  tract.  If 
the  fistula  is  short  and  the  stomach  in  close  connection  with  the  abdom- 
inal wall,  the  closure  can  be  effected  without  opening  the  peritoneal 


220  SURGICAL    DIAGNOSIS  AXI)    IREATiMKNT. 

cax'ity.  An  incision  about  two  inches  in  length  down  to,  but  not 
through,  the  peritoneum  exposes  the  opening  in  the  stomach.  The 
edges  of  the  whole  fistulous  tract  should  next  be  thoroughly  freshened 
by  paring  them  with  a  sharp  knife  or  scissors. 

Four  rows  of  sutures  are  then  applied,  as  follows : 

1.  Fine  silk  pa.ssing  through  the  mucous  and  submucous  coats. 

2.  Catgut  sutures  to  include  the  remainder  of  the  stomach-wall. 

3.  A  deep  row  of  catgut  to  unite  the  deep  layers  of  the  abdominal 
wall. 

4.  A  row  of  silkworm  gut  to  unite  the  skin.  Over  this  a  copious 
aseptic  dressing  is  applied  and  retained  by  long  strips  of  adhesive 
jilaster.  The  stomach  is  kept  at  rest  by  giving  all  nutriment  by  the 
rectum  for  the  first  four  or  five  days. 

When  the  fistulous  tract  is  larger  and  the  stomach  is  not  in  close 
connection  with  the  abdominal  wall,  the  peritoneal  cavity  must  be 
entered.  The  stomach  is  completely  separated  wherever  it  is  found 
to  be  adherent  to  the  parietes,  and  the  opening  closed  as  in  wounds  of 
this  viscus. 

Cancer  of  the  Stomach. — "  Obscure  in  its  symptoms,  frequent  in 
its  recurrence,  fatal  in  its  event."  Such  is  the  description  of  cancer  of 
the  stomach  given  by  Brinton. 

Of  the  tumors  found  in  connection  with  the  stomach,  carcinoma  is 
by  far  the  most  common.  Sarcoma  is  exceedingly  rare.  Benign 
tumors  are  seldom  found  in  this  locality,  and,  if  they  do  exist,  require 
no  surgical  treatment.  Of  all  cases  of  cancer,  35  to  45  per  cent,  occur 
in  the  stomach,  which  is  more  liable  to  the  disease  than  any  other  part 
of  the  alimentary  canal  except  the  tongue  and  lips.  The  maximum 
liability  lies  between  the  ages  of  fifty  and  sixty.  It  is  rare  before  the 
thirtieth  year,  and  congenitally  it  almost  never  occurs. 

True  to  the  pathological  law  that  carcinoma  is  most  likely  to  occur 
where  two  kinds  of  epithelial  cells  meet,  cancer  of  the  stomach  begins, 
as  a  rule,  either  at  the  cardiac  or  pyloric  orifice.  One-half  of  all  cases, 
according  to  Bernays,  begin  at  the  pylorus.  Of  903  cases  analyzed  by 
Gussenbauer  and  Winnewarter,  542  were  pyloric.  The  pylorus  is  per- 
haps more  susceptible,  owing  to  repeated  slight  injury  due  to  the 
passage  through  it  of  hard  or  indigestible  masses  of  food.  It  is  quite 
a  common  thing  to  find  post-mortem  old  cicatrices  in  the  mucous 
membrane  of  this  locality,  which,  combined  with  the  clinical  fact  that 
cancer  has  a  tendency  to  occur  in  scar-tissue,  gives  some  show  of 
reason  to  the  theory. 

Next  in  frequency  of  situation  is  cancer  of  the  greater  curvature. 
In  other  positions  the  disease  is  extremely  rare.  Once  the  neoplasm 
has  started,  it  tends  to  grow  toward  the  lumen  of  the  stomach.  The 
mucous  membrane  is  the  structure  first  affected ;  next  the  submucous 
loose  connective  tissue ;  and  only  in  the  last  stage  are  the  muscular 
and  serous  coats  invaded.  Early  and  accurate  diagnosis  is  of  the 
utmost  importance,  and  I  would  submit  the  following  points  as  a 
practical  mode  of  procedure  in  any  case  of  suspected  gastric  cancer : 

I.  History. — If  a  patient  more  than  forty  years  of  age  gives  a 
history  of  disturbed  digestion  dating  back  for  several  months  or  a 
year,  combined  with  cardiac  or  pyloric  stenosis,  the  suspicion  of  cancer 


INJURIES  AND  DISEASES   OF   THE  DIGESTIVE  SYSTEM.       221 

of  the  stomach  must  be  entertained.  Pain,  as  a  rule,  is  not  felt  until 
an  advanced  stage  of  the  disease.  Vomiting  occurs  without  much 
effort  and  with  little  nausea.  At  first  the  vomit  consists  chiefly  of 
mucus,  remnants  of  food,  and  watery  fluid  mixed  with  bile,  but  by 
degrees  the  stomach-contents  are  expelled  in  a  more  and  more  undi- 
gested state.  It  is  not  until  ulceration  has  become  established  that 
blood  is  vomited.  The  blood  may  be  in  small  amounts  as  bright-red 
streaks  in  the  mucus,  or  the  quantity  may  be  large  and  changed  in 
appearance  according  to  the  length  of  time  it  has  remained  in  the 
stomach  and  the  changes  it  has  there  undergone.  Then  it  may  be  in 
bright-red  or  brownish-red  clots  or  coagula,  vaiying  in  shade  from 
brown  chocolate  color  to  black.  This,  the  so-called  "  coffee-grounds  " 
vomit,  was  formerly  supposed  to  be  pathognomonic  of  cancer  of  the 
stomach,  but  experience  has  proved  this  to  be  an  unreliable  sign,  for 
other  diseases  are  attended  with  "  coffee-grounds  "  vomit. 

At  the  same  time  it  must  be  borne  in  mind  that,  as  a  rule,  the  blood 
remains  longer  in  the  stomach  in  cancer  than  in  other  diseases,  and 
"  coffee-grounds  "  vomit  has  therefore  considerable  significance,  con- 
sidered with  loss  of  strength  and  progressive  emaciation.  The  fat  and 
muscles  rapidly  waste  away,  and  ere  long  the  patient  becomes  decidedly 
emaciated. 

2.  Physical  Examination. — In  all  cases  of  abdominal  examination  it 
is  convenient  to  map  out  by  means  of  a  colored  pencil  the  abdominal 
areas — viz.  epigastric,  right  and  left  hypochondriac,  etc.  Besides  these 
I  would  draw  a  line  from  the  points  of  the  false  ribs  on  either  side  to 
the  umbilicus.  On  the  right  side  this  line  with  the  linea  alba  and  line 
of  the  false  ribs  forms  a  triangle  in  which  tumors  of  the  pylorus  are  to 
be  sought  for.  On  the  left  side  the  line  marks  the  boundary  of  normal 
stomach-dilatability.  If  the  stomach  falls  below  this  line,  we  may  say 
that  there  is  abnormal  dilatation.  For  a  thorough  examination  the 
patient  should  be  anesthetized. 

3.  Inspection. — Standing  at  the  patient's  feet  and  looking  down  upon 
him,  we  can  observe  an)'  irregularity  in  the  abdominal  wall.  A  growth 
in  the  stomach  may  be  visible  as  an  elevation  over  the  situation  of  the 
organ.  A  depression  in  the  epigastrium  points  to  obstruction  in  the 
esophagus,  a  fulness  in  the  epigastrium  to  pyloric  stenosis. 

4.  Palpation  and  Percussion. — We  may  expect  to  find  a  tumor  in 
three-fourths  of  the  cases.  A  tumor  at  the  cardiac  orifice  is  hard  to 
find  by  palpation,  owing  to  its  distance  from  the  surface.  It  is  only 
when  it  has  attained  considerable  size  that  its  presence  is  clearly  demon- 
strated. At  the  pyloric  end,  however,  the  tumor  is  more  easily  felt,  and 
its  common  position  is  between  the  ensiform  cartilage  and  the  umbilicus, 
a  little  to  the  right  of  the  middle  line.  Having  found  the  growth,  we 
may  ask  ourselves  the  following  questions  : 

First.  Is  the  tumor  movable  ?  Its  weight  may  drag  it  downward, 
so  that  it  falls  below  the  line  we  have  marked  upon  the  skin  from  the 
border  of  the  false  ribs  to  the  umbilicus.  If  freely  movable,  it  is  an 
indication  that  there  is  no  invasion  of  neighboring  organs.  Still,  this 
rule  cannot  be  insisted  upon,  for  in  one  recorded  case  the  tumor  was 
freely  movable,  and  yet  the  adhesions  were  so  strong  and  so  numerous 
that  the  operation  had  to  be  abandoned.     On  the  other  hand,  fixation 


222  SC'KGICAL    D/AGXOS/S  AND    TREATMENT. 

docs  not  certainly  indicate  extension  of  the  disease  to  neit^hboring 
structures.  W'lien  it  has  become  adherent  to  the  hver  and  diaphragm, 
it  rises  and  falls  with  respiration.  Dilatation  of  the  stomach  may  cause 
mobility  of  the  tumor.  If  the  stomach  be  greatly  dilated  and  the 
pylorus  fixed  in  an  abnormal  situation,  it  strongly  suggests  extension 
of  the  disease.  If  irregularity  of  the  surface  of  the  growth  coexists 
with  these  conditions,  we  may  certainly  infer  that  the  disease  has  spread, 
and  then  operation  is  out  of  the  question  (Greig  Smith). 

Second.  Is  the  stomach  dilated  ?  This  can  be  ascertained  by  dis- 
tending the  organ.  Frerichs  employed  for  this  purpose  carbonic-acid 
gas  generated  outside  the  body — for  example,  from  an  inv^erted  siphon 
of  mineral  water.  Safer  and  more  satisfactory  is  the  method  of  Rune- 
berg,  which  consists  in  introducing  a  stomach-tube  and  then  insufflating 
air  by  the  double  bulbs  of  a  spray  apparatus.  As  a  rule,  we  have  other 
reasons  for  introducing  the  tube,  so  that  the  inflation  of  the  stomach 
with  air  gives  very  little  additional  trouble.  Besides  percussion  of  the 
stomach,  we  may  with  advantage  employ  succussion  in  its  two  forms — 
viz.  digital  and  total  or  Hippocratic.  The  writings  of  Bouchard  have 
brought  this  matter  of  examination  into  considerable  prominence.  It 
is  thus  employed :  The  patient  lies  on  his  back  with  the  abdominal 
muscles  relaxed.  The  surgeon  makes  a  series  of  rapid  taps  with  the 
extremity  of  the  fingers  on  the  abdominal  wall  along  the  line  running 
from  the  umbilicus  to  the  edge  of  the  false  ribs  on  the  left  side.  If  a 
certain  amount  of  liquid  and  gas  is  present,  we  obtain  in  this  way  a 
sensation  of  splashing  to  which  Bouchard  attaches  great  importance. 
The  presence  of  a  gastric  succussion-sound  when  it  is  perceived  below  a 
line  extending  from  the  umbilicus  to  the  border  of  the  false  ribs  on  the 
left  side  indicates  a  permanent  dilatation  of  the  stomach.  It  is  import- 
ant only  when  obtained  a  long  time  after  a  meal,  and  especially  when  a 
patient  is  fasting  in  the  morning  (Mathieu). 

The  significance  of  dilatation  lies  in  the  fact  that  it  corroborates 
obstruction  at  the  pylorus.  Contraction,  on  the  other  hand,  argues  in 
favor  of  obstruction  at  the  cardiac  orifice. 

5.  Examination  of  the  Contents  of  the  Stojuach. — The  surgeon  is 
not  justified  in  neglecting  this  means  of  diagnosis  in  any  chronic 
gastric  disease.  As  the  procedure  is  not  yet  so  generally  employed 
as  its  importance  demands,  I  may  perhaps  be  pardoned  if  I  very 
hurriedly  run  over  the  steps  of  most  practical  utility  in  aiding  diag- 
nosis. 

It  is  important  in  the  examination  of  the  stomach-contents  that  a 
uniform   method  should  be  followed. 

Different  results  will  be  obtained  at  different  periods  of  the  digestive 
process.  A  scanty  diet  will  not  call  forth  the  activity  of  the  gastric 
glands  to  the  same  degree  as  a  hearty  meal.  For  conv^enience  and 
uniformity,  a  so-called  test  breakfast  is  given  on  an  empty  stomach,  and 
the  contents  are  drawn  off  an  hour  to  an  hour  and  a  half  afterward. 
This  breakfast  consists  of  an  ordinary  dry  roll  without  butter,  and  about 
two-thirds  of  a  pint  of  wx^ak  tea  or  coffee  without  milk  or  sugar. 
Such  a  repast  contains  albuminoids,  sugar,  starches,  non-nitrogenous 
extractives  and  salts,  thus  offering  the  stomach  all  the  ingredients  that 
are  usually  taken,  while  at    the   same   time   liquefaction    takes   place 


INJURIES  AND  DISEASES  OF  THE   DIGESTIVE   SYSTEM.       223 

rapidly,  and  there  are  no  solid  pieces  of  food,  such  as  meat,  to  plug  the 
opening  in  the  stomach-tube. 

The  patient  having  taken  the  test  breakfast  at  about  8.30  a.  m.,  pre- 
sents himself  at  9.30  or  10  for  examination.  To  obtain  the  stomach- 
contents,  the  simplest  plan  is  that  known  as  Ewald's  expression  method. 
A  soft-rubber  stomach-tube  is  passed,  and  when  the  end  has  entered 
the  stomach  from  twenty-three  and  a  half  to  twenty-five  and  a  half 
inches  from  the  incisor  teeth,  the  patient,  by  contraction  of  the  abdomi- 
nal muscles,  forces  the  stomach-contents  through  the  tube  into  a 
receiving  vessel.  This  fluid  is  then  filtered,  and,  as  a  rule,  presents  the 
appearance  of  an  amber-colored  liquid  resembling  normal  urine. 

Before  proceeding  further  we  must  bear  in  mind  that  during  digestion 
the  stomach  normally  has  acid  contents.  Ewald  and  Boas  by  numer- 
ous experiments  found  during  the  normal  digestion  of  the  test  break- 
fast the  following  three  stages : 

1.  As  early  as  ten  or  fifteen  minutes  after  a  meal  the  stomach- 
contents  often  are  acid.  The  acidity  depends  upon  the  free  acids,  acid 
salts,  or  both.  The  free  acid  is  the  lactic  acid.  Up  to  thirty  or  forty- 
five  minutes  the  lactic  acid  predominates,  while  the  color-tests  for 
hydrochloric  acid  are  negative. 

2.  Then  comes  a  stage  in  which  both  hydrochloric  and  lactic  acid 
can  be  found. 

3.  The  lactic  acid  disappears,  and  only  hydrochloric  acid  can  be 
found  after  the  first  hour.  The  secretion  of  hydrochloric  acid  begins, 
however,  immediately  after  the  food  is  taken. 

A  sample,  therefore,  drawn  one  hour  and  a  half  after  the  test  break- 
fast should  be  acid,  showing  a  total  acidity  of  40  to  65  per  cent,  as 
we  shall  afterward  explain,  and  this  acidity  should  be  due  to  hydro- 
chloric acid  in  the  proportion  of  14  to  24  per  cent.  The  questions  we 
have  to  answer  are  as  follow : 

1.  Are  the  stomach-contents  acid  ?  Litmus-paper  quickly  settles 
this  point. 

2.  How  acid  are  the  contents?  or,  in  other  words,  what  is  their  total 
acidity  ?  This  is  obtained  by  trituration  of  volumetric  solutions  and 
the  burette.  We  need  for  this  purpose  a  burette  and  two  solutions. 
The  first  is  a  decinormal  solution  of  caustic  soda.  The  atomic  weight 
of  caustic  soda  (NaHO)  is  40.  Forty  parts,  then,  of  soda  in  one 
thousand  parts  by  weight  of  distilled  water  is  a  normal  solution  (40  to 
I  liter).  A  decinormal  solution  is  one-tenth  of  this  strength,  or  4 
grams  to  a  liter.  The  other  reagent  is  a  solution  of  phenol-phthalein 
in  alcohol.  Phenol-phthalein  is  a  buff-colored  powder  freely  soluble  in 
alcohol.  It  remains  colorless  in  acid  or  neutral  solutions,  but  assumes 
a  carmine  color  in  alkaline  solutions. 

Fill  Mohr's  burette  with  the  decinormal  solution  of  caustic  soda. 
Into  a  glass  beaker  pour  10  c.c.  of  filtered  stomach-contents  and  add 
one  or  two  drops  of  the  phenol-phthalein  solution.  (It  gives  a  milky 
character  to  most  stomach-contents,  but  that  does  not  interfere  with 
the  test.)  Next  add  very  gradually  the  solution  in  the  burette.  As 
the  drops  fall  upon  the  fluid  in  the  beaker  a  carmine  color  is  produced 
which  disappears  on  shaking.  This  will  continue  as  long  as  the  contents 
of  the  beaker  are  acid.     When  the  carmine  color  no  longer  disappears 


224  SURGICAL    DIAGiVOSIS  AND    TREATMENT. 

on  shaking,  stop  and  read  off  the  number  of  c.c.  of  dccinormal  solution 
of  caustic  soda  which  have  been  employed.  Suppose  9^-  c.c.  have  been 
used  to  neutralize  10  c.c.  of  stomach-contents.  Ten  times  that  c[uantity, 
or  95  c.c,  would  be  required  to  neutralize  lOO  c.c.  It  is  convenient  to 
express  this  as  a  percentage  according  to  the  amount  of  decinormal 
solution  used.  In  this  case  95  c.c.  were  required  to  neutralize  100  c.c. 
Hence  we  express  it  as  95  per  cent,  total  acidity.  The  normal  acidity 
after  the  test  breakfast  is  40  to  65  per  cent.  So  that  in  the  sample 
before  us  the  total  acidity  is  too  great,  being  30  per  cent,  above  the 
normal  limit. 

At  this  point  I  might  state  that  if  we  knew  that  the  total  acidity  is 
due  to  hydrochloric  acid,  we  can  readily  calculate  the  amount  of  acid. 
Each  c.c.  of  soda  solution  used  represents  .003646  of  the  hydrochloric 
acid.  We  have  used  95  c.c,  which,  multiplied  by  .003646,  equals 
.346370  per  cent.     The  normal  limit  is  y^jj  to  y^^'^fj-  of  i   per  cent. 

The  next  point  is  to  determine  whether  the  acidity  is  due  to  the 
presence  of  free  acids  or  to  acid  salts.  The  readiest  method  is  by  the 
use  of  Congo-red  paper.  Dip  a  piece  of  Congo-paper  into  the  fluid  and 
slowly  dry  it.  The  bright  red  is  changed  to  a  sky-blue,  showing  the 
presence  of  a  free  acid. 

3.  What  acids  are  present  ?  The  most  important  are  hydrochloric, 
lactic,  butyric,  and  acetic. 

For  the  detection  of  hydrochloric  acid  the  best  test  is  Giinzberg's 
reagent.  It  surpasses  the  anilin  dyes  and  all  the  other  tests,  being  so 
delicate  as  to  show  hydrochloric  acid  when  it  is  as  low  as  i  in  20,000. 
The  reagent  is  made  as  follows : 

Phloroglucin,  gr.  30; 

Vanillin,  gr.  15  ; 

Absolute  alcohol,  5J. 

Nothing  can  be  more  simple  than  the  application  of  this  test.  Take 
a  small  porcelain  dish  and  place  upon  it  two  or  three  drops  of  the  gas- 
tric contents,  and  add  an  equal  quantity  of  the  reagent.  Now  gently 
heat  the  dish  over  a  spirit  lamp,  and  as  the  fluid  evaporates  around  the 
edges  will  be  seen  a  bright  rosy-red  color.  Blowing  upon  it,  and  thus 
aiding  evaporation,  brings  out  the  color  more  distinctly.  This  is  proof 
positive  of  the  presence  of  hydrochloric  acid,  and  from  the  intensity  of 
the  color  may  be  roughly  estimated  the  amount  of  hydrochloric  acid 
present.  We  know  that  the  limit  of  reaction  lies  at  i  to  20,000.  By 
successively  diluting  the  stomach-contents  one-third,  one-fifth,  one- 
tenth,  till  the  reaction  is  no  longer  obtained,  we  can  roughly  estimate 
the  amount  of  hydrochloric  acid. 

The  next  acid  to  search  for  is  lactic  acid.  Until  recently  it  was 
believed  that  the  presence  of  any  of  the  organic  acids  was  patho- 
logical, since  it  was  proved  that  the  only  acid  secreted  by  the  gastric 
glands  is  hydrochloric  acid.  Ewald  and  Boas,  however,  found  that 
lactic  acid  can  generally  be  detected  in  the  early  stages  of  digestion  in 
healthy  stomachs,  and  that  this  condition  is  normal.  If  organic  acids 
are  found  in  the  later  stages  in  such  quantities  that  they  can  be  detected 
with  the  ordinary  reagents,  then  they  always  have  a  pathological  sig- 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE   SYSTEM.       225 

nificance.     They  are  the  results  of  fermentation  of  some  of  the  sub- 
stances acted  upon  by  the  gastric  juices,  such  as  sugar  and  albumins. 

Lactic  acid  can  exist  under  two  conditions  :  (i)  as  the  result  of 
fermentation  ;  and  (2)  as  it  exists  normally  in  meat  in  the  form  of 
sarcolactic  acid.  In  chemical  character  these  two  forms  do  not  differ 
from  one  another. 

The  simplest  test  for  lactic  acid  is  the  neutral  ferric-chlorid  solution. 
A  diluted  solution  of  this  salt  turns  canary  yellow  in  the  presence  of 
lactic  acid.  The  only  difficulty  about  this  test  is  that  we  have  to  dis- 
tinguish between  two  shades  of  yellow.  We  are  indebted  to  Uffelmann 
for  an  excellent  improvement  upon  this  method.  He  takes  a  few  drops 
of  a  neutral  ferric-chlorid  solution  and  adds  one  or  two  drops  of  pure 
carbolic  acid  (or  about  10  c.c.  of  a  2|  per  cent,  solution  of  carboHc 
acid) ;  he  then  adds  water  until  the  solution  assumes  a  beautiful 
amethyst-blue  color.  If  to  this  fluid  be  then  added  even  a  trace  of 
lactic  acid,  the  canary-yellow  color  is  produced ;  fatty  acids  produce  an 
ashy-gray  color ;  if  inorganic  acids  are  present,  the  solution  is  decolor- 
ized. So  delicate  is  the  test  that  lactic  acid  can  be  detected  in  solutions 
containing  i  :  2000.  « 

4.  What  is  the  digestive  power  of  the  stomach  ?  The  albuminates 
are  changed  in  the  healthy  stomach  into  propeptones  and  peptones, 
which  are  thus  examined : 

{a)  Propeptones.  To  a  small  quantity  of  the  filtrate  add  an  equal 
part  of  a  saturated  solution  of  sodium  chlorid.  If  propeptone  is 
present,  it  is  precipitated,  and  the  more  turbid  the  fluid  becomes  the 
greater  is  the  quantity  of  propeptone.  When  no  precipitate  is  formed, 
add  a  drop  or  two  of  acetic  acid ;  the  precipitate  quickly  follows  if 
propeptone  is  present.  On  heating,  the  precipitate  is  dissolved,  but 
returns  as  soon  as  the  fluid  cools. 

{6)  Peptone.  After  precipitating  the  propeptone  and  filtering,  the 
filtrate  is  made  strongly  alkaline  by  the  addition  of  a  solution  of  sodium 
hydrate.  A  few  drops  of  a  i  per  cent,  solution  of  sulphate  of  copper 
are  then  added.  A  violet-red  or  purplish  color  is  produced  if  peptone 
is  present 

[c)  Pepsin.  A  disc  i  mm.  in  thickness  and  i  cm.  in  diameter  of  the 
white  of  a  hard-boiled  q%^  is  added  to  5  c.c.  of  the  filtrate  in  a  test-tube 
and  kept  at  the  temperature  of  the  blood.  If  pepsin  is  present,  the  &^^ 
disc  is  digested  and  disappears  in  from  two  to  six  hours.  If  the  filtrate 
contains  no  hydrocHloric  acid,  a  few  drops  of  the  dilute  acid  should  be 
added. 

[d^  Rennet  ferment.  To  5  c.c.  of  milk  in  a  test-tube  add  three  or 
four  drops  of  the  filtrate.  After  thoroughly  mixing  place  the  tube  in  a 
glass  of  warm  water.  If  rennet  ferment  be  present,  the  milk  will 
become  curdled  in  from  ten  to  fifteen  minutes. 

Starchy  foods  are  converted  into  dextrin,  erythrodextrin,  achroodex- 
trin,  and  maltose.  The  test  for  all  of  them  is  Lugol's  solution  (iodin 
0.1,  potassium  iodid  0.2,  distilled  water  200).  A  few  drops  of  the 
solution  are  added  to  a  small  quantity  of  the  filtrate.  The  result  is  as 
follows : 

{a)  Dextrin  turns  the  fluid  blue. 
if)  Erythrodextrin  turns  it  red. 


226  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

ic)  Achroodcxtrin  discolors  the  solution. 

(r/)  Maltose  does  not  change  the  color  of  the  solution. 

Wliat  do  we  learn  by  this  examination  ?  Simply  this  :  If  hydro- 
chloric acid  be  present  in  normal  amount,  it  is  strong  evidence  against 
cancer.  If  it  be  absent  or  greatly  diminished,  it  is  very  strong  cor- 
roborative evidence  of  the  existence  of  a  cancer.  Much  discussion  has 
taken  place  on  this  question.  When  Vander  Velden  expressed  the 
opinion  that  cancer  of  the  pylorus  accompanied  by  dilatation  of  the 
stomach  leads  to  suppression  of  hydrochloric  acid,  the  view  was 
rapidly  applied  to  all  forms  of  cancer  of  the  stomach  indiscriminately. 
Later  investigations  showed  that  this  statement  could  not  be  main- 
tained in  its  entirety,  yet  it  has  led  to  results  of  great  diagnostic  and 
therapeutic  significance.  When  the  new  growth  is  confined  to  a  small 
area,  when  the  accompanying  catarrh  of  the  mucous  membrane  is 
moderate,  and  when  there  is  no  atrophy,  then  the  secretion  of  hydro- 
chloric acid  may  remain  ample.  Clinically,  however,  one  of  these 
features  is  absent,  and  the  secretion  of  hydrochloric  acid  is  entirely 
annihilated  or  is  reduced  to  the  smallest  quantity.  It  is  true  that  other 
conditions  of  the  stomach  give  rise  to  a  diminution  of  the  secretion. 
These  conditions  are  atrophy  and  amyloid  degeneration  of  the  mem- 
brane, mucous  catarrh,  and  certain  neuroses,  but,  notwithstanding  all 
this,  the  absence  of  hydrochloric  acid  seldom  fails  clinically  to  cor- 
roborate a  diagnosis  of  cancer  of  the  stomach. 

The  significance  of  lactic  acid  has  been  recently  receiving  atten- 
tion. Boas  uses  as  a  test  meal  flour  soup  quite  free  from  lactic 
acid,  and  states  that  this  acid  was  never  found  in  any  conditions 
except  those  of  carcinoma.  His  results  have  been  confirmed  by 
Dr.  D.  Stewart* 

Ischochymia,  or  the  retention  of  chyme  in  the  stomach,  is  a  symp- 
tom of  great  value.  In  this  condition  the  organ  has  not  the  power  to 
empty  itself,  and  contains  food  even  while  the  patient  is  fasting.  As  a 
rule,  it  is  associated  Avith  dilatation  of  the  stomach,  and  the  commonest 
cause  of  dilatation  is  stricture  at  the  pylorus.  But  dilatation  is  not 
necessarily  present,  for  it  does  not  usually  appear  until  the  stricture  at 
the  pylorus  has  existed  for  some  time.  The  value,  then,  of  ischo- 
chymia as  a  symptom  lies  in  the  fact  that  it  can  be  recognized  at  an 
earlier  period  in  the  disease  than  that  at  which  dilatation  can  be  detected. 
To  recognize  the  condition  it  is  necessary  to  examine  the  stomach- 
contents  while  the  patient  is  fasting.  Einhorn  instructs  his  patient  to 
have  at  his  supper  on  the  night  preceding  the  examination  soup,  meat, 
bread,  and  some  rice,  as  this  latter  is  very  easily  recognized,  and,  as  a 
rule,  retained  in  the  stomach  when  there  is  stricture  of  the  pylorus. 
The  stomach-tube  is  employed  in  the  usual  manner,  and  if  no  chyme 
can  be  withdrawn  by  expression,  it  is  necessary  to  wash  out  the  stomach. 
If  ischochymia  is  present,  the  rice  and  particles  of  the  other  articles  of 
diet  are  found  in  an  undigested  state. 

Microscopic  examination  may  sometimes  throw  light  on  the  case. 
In  the  vomited  matter,  in  the  gastric  contents  obtained  after  a  test 
breakfast,  in  the  washings  after  lavage,  or  in  the  tube  after  an  explora- 
tory examination  shreds  or    small    particles  of  tissue  may  be  found. 

1  Medical  Record,  Mar.  9,  1S95,  quoting  from  Medical  News. 


INJURIES  AND   DISEASES   OF  THE  DIGESTIVE   SYSTEM.       22/ 

These  should  be  examined  under  the  microscope,  and  may  decide  the 
question  of  cancer. 

Examination  of  the  urine  may  be  employed  for  further  testimony. 
The  presence  of  indican,  which  is  the  form  in  which  indol  is  eliminated 
from  the  urine,  is  perhaps  suggestive  of  cancer,  but  as  it  may  be  found 
in  almost  any  wasting  disease,  its  diagnostic  value  is  not  worth  men- 
tioning. Its  qualitative  determination  is  very  easy.  Take  lo  c.c.  of 
hydrochloric  acid  and  i  c.c.  of  chloroform.  To  this  add  lo  c.c.  of 
urine,  and  by  means  of  a  glass  rod  add  one  or  two  drops  of  a  con- 
centrated solution  of  chlorid  of  calcium.  The  mixture  is  next  shaken, 
and,  if  indican  be  present,  the  chloroform  assumes  a  blue  color,  due  to 
the  formation  of  indigo. 

Gastroscopy,  or  the  examination  of  the  gastric  mucosa  by  electric 
illumination,  is  not  only  of  little  value,  but  dangerous. 

Gastro-diaphany,  or  transillumination  of  the  stomach,  has  never  come 
into  general  use. 

In  spite  of  all  the  care  that  can  be  exercised,  some  cases  of  gastric 
carcinoma  will  prove  puzzling,  to  say  the  least.  The  gastric  crises  of 
locomotor  ataxy  have  been  mistaken  for  the  symptoms  of  pyloric 
cancer,  and  operated  upon  to  find  no  evidence  of  malignant  disease  or 
pyloric  obstruction.  Gastric  cancer  has  been  mistaken  for  pernicious 
anemia,  and  transfusion  of  blood  resorted  to.  Simple  fibroid  contrac- 
tion of  the  pylorus  is  often  indistinguishable  from  scirrhus,  except  after 
microscopic  examination.  Moreover,  cancer  of  the  stomach  may  occur 
without  any  symptoms  whatever,  and  be  discovered  after  death  from 
other  causes.  Such  being  the  status  of  our  methods  of  research,  we 
have  to  resort  to  something  more  definite  in  search  of  evidence,  and 
complete  the  examination  in  these  doubtful  cases  by  making  an  ex- 
ploratory incision.  To  quote  the  words  of  Loreta :  "  It  may  now  be 
accepted  as  a  maxim  in  surgery  that  an  exploratory  abdominal  incision 
is  to  be  recommended  in  cases  of  malignant  disease  of  the  stomach 
where  a  diagnosis  cannot  be  arrived  at  by  other  means." 

Are  there  any  conditions  under  which  the  diagnosis  of  cancer  can 
be  positively  made  without  exploratory  incision  ?  Einhorn  gives 
the  following  as  sufficient  evidence  to  answer  this  question  in  the 
affirmative : 

If  particles  of  tumor  are  found  (in  the  wash-water  or  in  the  sound) 
which  under  the  microscope  reveal  the  characteristic  picture  of  a 
malignant  growth  ; 

The  presence  of  a  more  or  less  large  tumor  with  an  uneven  surface, 
belonging  to  the  stomach  and  associated  with  dyspeptic  symptoms  ; 

The  presence  of  a  tumor  associated  with  frequent  hematemesis  ; 

Constant  pains,  frequent  vomiting,  ischochymia,  emaciation,  all  these 
symptoms  being  quite  permanent,  and  not  extending  over  too  long  a 
period  of  time  (six  months  to  one  year) ; 

Tumor  and  ischochymia ; 

Emaciation,  ischochymia,  presence  of  lactic  acid. 

Constant  anorexia  and  pain,  not  yielding  to  treatment,  accompanied 
by  frequent  small  hemorrhages  (of  coffee-ground  color). 

Treatment. — The  surgical  treatment  of  carcinoma  of  the  stomach 
may  be  curative  or  palliative  in  its  aim. 


228  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

The  simplest  and  most  readily  ai)plicable  remedy  is  lavage.  Ewald 
calls  it  the  sovereign  remedy  for  dilatation.  The  ordinaiy  stomach- 
tube  with  funnel  attached  is  all  the  apparatus  required.  Warm  water 
in  large  quantities  should  be  alternately  introduced  and  removed  by 
siphonage  until  turbidity  ceases  and  all  shreds,  fragments  of  food,  or 
flakes  of  mucus  cease  to  come  away.  This  treatment  is  of  course 
but  palliative.  Obstruction  at  the  cardiac  orifice  may  prohibit  the 
employment  of  lavage  and  may  call  for  more  formidable  measures. 
Life  may  be  prolonged  by  keeping  the  strictured  portion  patent  by 
dilating  it  with  esophageal  tubes.  Through  the  tubes  liquid  and  finely- 
divided  food  may  be  introduced.  In  far-advanced  stenosis  a  small 
rubber  tube  or  catheter  may  be  introduced  by  one  of  the  nasal 
passages,  retained  in  position,  and  through  it  liquids  injected  into  the 
stomach. 

Failing  in  this,  operative  procedures  may  be  resorted  to.  The 
available  surgical  procedures  resolve  themselves  into — i.  pylorectomy; 
2.  gastro-enterostomy ;  3.  combined  pylorectomy  and  gastro-enter- 
ostomy;  4.  gastrotomy ;  5.  jejunostomy;  6.  curettage  of  the  cancerous 
portion  of  the  stomach. 

At  the  pylorus  the  disease  is  more  accessible,  and  if  diagnosed 
at  an  early  stage  and  operated  upon  before  the  glands  becomes  in- 
volved or  adhesions  have  formed,  the  operation  of  pylorectomy  is 
indicated. 

The  history,  so  far,  has  not  been  very  encouraging.  Bremer  col- 
lected 72  cases  with  a  mortality  of  76  per  cent.  Winslow  found  prac- 
tically the  same  ratio  in  a  smaller  number  of  cases.  Of  18  cases  which 
I  have  been  able  to  collect  in  the  past  two  years,  8  recovered  and  10 
died.  The  time  may  come  when  a  remedy  for  cancer  will  be  found, 
but  at  present  our  hope  for  radical  cure  lies  in  early  diagnosis  and 
complete  removal.  Could  these  two  conditions  be  complied  with,  the 
results  following  pylorectomy  would  be  much  more  favorable  than  our 
present  figures  show.  Gastro-enterostomy  is  a  palliative  operation, 
and  shows  better  results  than  pylorectomy.  The  mortality  is  lower 
and  prolongation  of  life  is  from  two  months  to  a  year  or  more,  while  in 
pylorectomy  the  immediate  dangers  of  the  operation  are  much  greater, 
and  in  those  who  survive  the  disease  proves  fatal  in  a  period  varying 
from  four  to  eight  months.  In  the  early  operations,  according  to  Bill- 
roth, the  mortality  was  50  per  cent.  Liicke  of  Strasburg  reduced  it  to 
31   per  cent. 

Gastro-enterostomy  does  not  cure  the  disease,  but  it  very  often 
brings  about  a  very  noticeable  improvement  in  the  local  and  general 
conditions,  showing  what  an  important  part  the  pyloric  stenosis  plays 
in  the  production  of  many  of  the  symptoms.  The  pain  also  disappears. 
This  is  explained  by  the  fact  that  the  stomach-contents  no  longer  come 
in  contact  with  the  cancerous  ulceration,  but  pass  directly  into  the 
small  intestines  along  the  new  route  opened  up  by  the  operation.  This 
is  why  in  similar  cases  the  employment  of  lavage  is  followed  by  so 
much  relief  (Mathieu). 

In  the  Annals  of  Surgery  for  December,  1887,  Dr.  Bernays  of  St. 
Louis  described  an  operation  whereby,  after  making  an  incision  in  the 
walls  of  the  stomach,  he  removes  by  curette  or  other  suitable  instrument 


INJURIES  AND   DISEASES    OF   THE   DIGESTIVE   SYSTEM.        229 

cancerous  growths  bulging  into  the  stomach-cavity.  His  method  con- 
sists in — first,  an  accurate  examination  of  the  outside  of  the  stomach. 
He  then  fixes  a  fold  of  the  stomach  to  the  parietal  wound  by  numerous 
sutures.  The  stomach  is  now  opened  and  its  lips  carefully  stitched  to 
the  lips  of  the  wound  in  the  parietes.  The  stomach-cavity  being  com- 
pletely shut  off  from  the  abdominal  cavity,  he  proceeds  with  fingers 
and  curette  to  tear  and  scrape  away  masses  of  the  growth.  Bleeding 
is  free,  but  soon  ceases.  The  results  of  the  operation  in  several 
cases  have  been  fairly  satisfactory,  but  a  radical  cure  cannot  be  relied 
upon. 

Stricture  of  the  Cardiac  Orifice. — Stenosis  of  either  orifice  of 
the  stomach  may  be  a  result  of  carcinoma,  or  may  be  due  to  the 
cicatricial  contraction  which  follows  the  healing  of  an  ulcer  or  a  wound 
caused  by  a  foreign  body. 

The  first  symptom  to  attract  attention  to  stenosis  of  the  cardiac 
orifice  is  a  gradually  increasing  difficulty  in  swallowing  solid  food. 
Liquids  can  pass  through  the  narrowed  opening,  but  with  less  rapidity 
than  in  the  normal  condition  ;  solids  are  regurgitated.  The  epigastrium 
is  often  retracted  and  the  stomach  collapsed,  strongly  contrasting  with 
the  full  epigastrium  and  dilated  stomach  which  attend  stenosis  of  the 
pyloric  orifice.  The  passage  of  olive-pointed  bougies,  as  in  the  case  of 
esophageal  stricture,  will  confirm  the  diagnosis.  The  question  of 
malignancy  must  be  settled  by  the  age  of  the  patient  and  the  history  of 
the  case. 

Stricture  of  the  pylorus  is  in  the  vast  majority  of  cases  due  to  car- 
cinoma. As  the  lumen  of  the  pylorus  becomes  lessened,  and  there 
is  increasing  obstruction  to  the  passage  of  the  gastric  contents  toward 
the  intestine,  dilatation  of  the  stomach  results,  and  is  a  prominent- 
symptom. 

A  case  of  pyloric  stricture  has  a  history  of  long-continued  dyspepsia, 
and  every  chronic  dyspeptic  should  be  carefully  examined  for  this 
condition. 

It  is  not  uncommon  to  find  such  a  stomach  rejecting  food  which  has 
remained  in  it  for  days  or  even  weeks.  If  the  stomach-tube  be  used, 
the  contents  may  be  found  to  amount  to  several  quarts,  and  the  dis- 
tended organ  may  reach  considerably  below  the  umbilicus.  The  pres- 
ence of  a  tumor  in  the  pyloric  region  must  not  be  depended  upon  as  a 
diagnostic  point,  for,  although  the  absence  is  indicative  of  cicatricial 
stenosis,  some  of  the  worst  cases  of  cancerous  stricture  afford  no 
evidence  of  a  tumor. 

Einhorn  thus  tabulates  the  differential  diagnosis  between  benign  and 
malignant  stenosis  of  the  pylorus  : 

Differential  Diagnostic  Points. 

Benign  Stenosis  of  Malignant  Stenosis  of 

Pylorus.  Pylorus. 

Tj       ,-         /•  .,,  r  Long  duration  of  illness  (two  to     Short    duration    of    illness     (five 

Duration  of  illness.       <       rf:  .  ^  ^,     .  j     u  ir  \ 

t       fifteen  years).  months  to  one  and  a  half  years). 

(T          •  .        1       -lu     .       •  No   periods    of  perfect   euphoria, 

Long  intervals  without  pain,  or  ,1          ..     »       j         j     1 

^ .   J      c        r    »         u     •  but  constant  and  gradual  aggra- 

penods  of  perfect  euphoria.  .         r           ,    "               °^ 

r                  r                r  vation  oi  symptoms. 

Tumor.  As  a  rule,  absent.  Present  in  most  cases. 


230 


SURGICAL    DIAGNOSIS  AND    TREATMENT. 


Free  HCl. 

Lactic  acid. 

Acidity. 
Rennet. 
Odor. 


Condition  of  Gastric  Contcttts. 


Benign  Stenosis  of 
Pylorus. 


Malignant  Stenosis  of 
Pylorus. 


f  Present  in  the  great  m.ijority  of  Nearly  always  absent. 
\        cases. 

(  Absent  in  the  great  majority  of  As  a  rule,  present. 
\      cases. 

Always  increased.  Fluctuates  between  30  and  90. 

Always  present.  Varies. 

Unpleasant,  disagreeable.  Very  frequently  fetid. 


Treatment. — Non-cancerous  stricture  of  the  cardiac  orifice  should  be 
treated  by  the  introduction  of  bougies  gradually  increased  in  size  until 
the  largest  instruments  can  be  passed.  Nor  should  the  treatment  cease 
at  this  stage.  Full-sized  bougies  should  be  passed  once  or  twice  a  week 
to  prevent  recontraction.  When  this  method  of  treatment  fails,  gas- 
trostomy must  be  resorted  to  for  the  double  purpose  of  supplying  the 
stomach  with  food  and  of  dilating  the  stricture  from  below.  The 
manner  of  carrying  out  this  procedure  is  described  under  Esophageal 
Stricture. 

At  the  pyloric  orifice  the  measures  to  be  adopted  are  forcible  dilata- 
tion through  an  opening  in  the  stomach,  the  various  plastic  operations, 
and  gastro-enterostomy. 

Forcible  dilatation  was  first  practised  by  Loreta  in  1883.  He  made 
an  incision  in  the  stomach  a  little  nearer  to  the  pylorus  than  to  the 
cardiac  end.  Through  this  opening  he  introduced  the  index  finger  of 
the  right  hand  and  passed  it  through  the  stricture.  The  fore  finger  of 
the  other  hand  was  then  inserted,  and  by  separating  the  fingers  the 


Fig.  105.  Pyloroplasty:  i,  linear  incision  ;  2,  the  final  result.  The  lower  series  of  figures 
show  the  transformation  of  the  horizontal  linear  incision  (3)  into  the  oval  (4),  the  sutures  (5) 
converting  it  finally  into  (6)  a  vertical  linear  incision  (Heineke  and  Mikulicz). 

stricture  was  forcibly  stretched.  The  gastric  opening  was  closed,  as  in 
gastrotomy  for  other  purposes.  This  operation  is  attended  with  con- 
siderable danger,  and  has  been  largely  replaced  by  the  pyloro-plastic 
operation  of  Heineke  and  Mikulicz. 

The   operation   consists    in    making  a   longitudinal   incision   at  the 


INJURIES  AND  DISEASES   OF   THE  DIGESTIVE   SYSTEM.        23 1 

pylorus,  and  then  suturing  it  so  that  it  becomes  transverse.  First 
Step :  After  preparation  of  the  patient  by  washing  out  the  stomach 
with  boracic-acid  solution  or  salicylated  water,  an  incision  is  made  in 
the  middle  line  from  the  ensiform  cartilage  to  the  umbilicus,  the  pylorus 
brought  to  the  opening  and  packed  around  with  sponges.  Second 
Step :  An  incision  is  made  into  the  pylorus  and  extended  one  inch 
along  the  stomach  and  one  inch  along  the  duodenum  (Fig.  105). 
Third  Step :  Place  a  tenaculum  at  the  middle  of  each  side  of  the 
pyloric  incision  and  draw  the  edges  apart.  The  line  of  incision  will 
thus  become  transverse  to  the  axis  of  the  stomach.  In  this  position 
two  rows  of  sutures  are  applied — first  at  the  angles,  and  lastly  in  the 
central  portion  of  the  wound. 

The  results  of  this  operation  have  been  very  encouraging.  It  is 
attended  with  no  more  danger  than  a  gastrostomy,  and  when  properly 
performed  recurrence  of  the  stenosis  is  impossible.  For  cancerous 
stenosis  it  is  of  no  value. 

Gastro-enterostomy  is  the  operation  by  which  a  communication  is 
established  between  the  stomach  and  the  upper  part  of  the  small  intes- 
tine. Wolfler  was  the  first  to  propose  and  practise  this  operation.  His 
technique  has  been  improved  upon,  and  at  the  present  time  operators 
resort  to  one  of  two  methods — the  approximation  by  Senn's  decalcified 
bone-plates  or  the  anastomosis  by  Murphy's  button.  The  junction 
with  the  intestine  should  be  made  from  twenty-four  to  thirty  inches 
below  the  pylorus.  As  this  point  is  difficult  to  find,  the  following 
directions  may  be  useful :  The  first  loop  of  intestine  presenting  itself 
at  the  abdominal  wound  should  be  brought  out  and  held  by  an  assist- 
ant. The  operator  then  follows  the  intestine  in  one  direction.  If  this 
happens  to  be  toward  the  pylorus,  the  intestine  will  be  found  to  grow 
paler  and  the  walls  thicker  as  the  duodenum  is  approached.  The 
duodeno-jejunal  fold  is  taken  as  a  landmark,  and  a  point  twenty-four 
to  thirty  inches  from  it  is  selected  for  the  intestinal  opening.  Should 
the  operator  find  that  the  bowel  becomes  thinner  and  its  color  increas- 
ing to  a  bright  red,  he  may  know  that  he  is  going  away  from  the 
pylorus,  and  must  drop  that  part  and  start  out  in  the  opposite  direc- 
tion. The  application  of  the  bone-plates  or  button  is  the  same  as  in 
intestinal  anastomosis,  described  already. 

Dilatation  of  the  Stomach. — This  is  a  condition  attended  with 
much  more  serious  consequences  than  might  at  first  thought  appear. 
A  dilated  stomach  may  be  defined  as  one  that  cannot  empty  itself 
(Mathieu).  A  distinction  must  be  made  between  distention  and  dila- 
tation. A  distended  stomach  gradually  disposes  of  its  contents,  and 
at  the  end  of  the  interval  between  meals,  as  in  the  early  morning,  the 
organ  is  empty.  A  dilated  stomach,  on  the  other  hand,  has  not  the 
power  to  empty  itself,  and  in  it  may  be  found  food  which  has  remained 
there  for  days  or  even  weeks.  This  retention  of  food  is  followed  by 
fermentation  and  the  production  of  toxic  substances,  so  that  the  patient 
is  poisoned  by  the  material  formed  in  his  own  stomach.  An  extreme 
dilatation  of  the  stomach  may  be  regarded  as  a  fatal  disease  unless 
relieved.     It  is  as  serious  in  its  effects  as  cancer  of  the  pylorus. 

Causes  of  Gastrcctasia. —  i.  Mechanical  dilatation  due  to  obstruction 
of  the  pylorus  and  to  organic  changes  in  the  wall  of  the  stomach.    Of 


232  SURGICAL    DIAGNOSIS  AXD    TREATMENT. 

this  variety  the  great  majority  of  cases  occur  in  connection  with  can- 
cer of  the  pylorus.  Chronic  gastritis  leads  to  atrophy  of  the  muscular 
tissues,  with  loss  of  contractility  and  elasticity,  and  lastly  to  dilatation. 

2.  Hyperchlorhydria,  or  the  excessive  secretion  of  hydrochloric 
acid,  is  a  frequent  cause  of  dilatation.  Such  cases  often  present 
symptoms  which  closely  resemble  gastric  cancer.  The  presence  of 
hydrochloric  acid  in  large  quantities  readily  settles  the  diagnosis. 
Early  treatment  is  of  the  utmost  importance,  for  it  not  infrequently 
happens  that  what  would  be  only  a  temporary  dilatation  may  become 
permanent,  even  after  the  hyperchlorhydria  has  disappeared. 

3.  Atony  of  the  Stomach. — In  this  variety  the  patients  suffer  from 
dyspepsia  of  nervous  character  and  the  disease  is  purely  medical. 
Proper  treatment  resorted  to  at  an  early  period  can  be  relied  upon  to 
prevent  dilatation. 

Symptoms  of  Dilatation. — When  stricture  of  the  pylorus  is  the 
cause,  there  is  usually  a  feeling  of  weight  at  the  epigastrium  or  there 
may  be  pain  more  or  less  severe.  Acid  eructations  often  prove  trouble- 
some, and  there  is  a  peculiar  kind  of  vomiting  which  is  pathognomonic. 
It  occurs  at  long  intervals,  two  or  three  days,  and  is  then  very  copious. 
Pints  or  quarts  of  liquids  are  ejected  containing  particles  of  food  but 
little  changed.  This  is  particularly  noticeable  if  a  patient  has  eaten 
Indian  corn,  peas,  beans,  or  other  vegetables.  Sometimes  the  vomited 
matter  contains  blood.  If  red  in  color,  it  is  suggestive  of  gastric 
ulcer;  if  black,  it  indicates  cancer.  If  the  stricture  is  in  the  duodenum 
and  below  the  entrance  of  the  common  bile-duct,  large  quantities  of 
bile  will  flow  backward  into  the  stomach  and  form  an  important  con- 
stituent of  the  vomited  matter.  The  patient  should  be  given  a  test 
breakfast,  and  about  an  hour  afterward  the  stomach-tube  should  be 
passed.  If  a  large  amount  of  fluid  is  removed  at  this  examination,  the 
diagnosis  of  dilatation  may  be  safely  arrived  at,  and  especially  if 
unchanged  food  be  observed  or  food  that  has  lain  in  the  stomach  for 
days.  Having  emptied  the  stomach,  it  can  be  distended  with  air  before 
the  tube  is  removed.  In  many  cases  the  form  and  size  of  the  organ 
can  be  seen  by  the  bulging  of  the  abdomen  ;  by  percussion  it  can  be 
accurately  mapped  out.  Roughly  speaking,  a  stomach  is  dilated  if  it 
comes  below  a  line  drawn  between  the  umbilicus  and  the  line  of  the 
false  ribs. 

When  dilatation  attends  hyperchlorhydria  the  pains  in  the  stomach 
are  delayed,  coming  on  three  or  five  hours  after  a  meal.  Frequently 
the  patients  are  aroused  from  sleep  by  the  pain,  which  persists  until 
vomiting  occurs   and  affords  relief. 

Remote  effects  of  gastric  dilatation  may  be  summed  up  as  follows  : 
In  the  nervous  system,  neuralgia,  headache,  insomnia,  melancholia, 
nightmare,  giddiness,  and  disorders  of  vision  ;  in  the  liver,  congestion 
and  enlargement.  The  respiratory  system  is  affected,  as  evidenced  by 
bronchitis,  asthma,  and  pharyngitis.  Albuminuria  and  peptonuria  are 
evidences  of  kidney-involvement. 

Treatment. — In  cases  due  to  atonic  dyspepsia  regulation  of  the  diet 
and  washing  out  of  the  stomach  will  greatly  aid  the  medical  treatment ; 
it  is  seldom  that  the  dilatation  is  so  great  as  to  necessitate  operative 
measures.     When  hyperchlorhydria  is  the  cause  the  stomach-tube  will 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE   SYSTEM.       233 

be  found  invaluable.  Washing  out  the  stomach  before  bedtime  ensures 
rest  for  the  night  and  saves  the  mucous  membrane  from  contact  with 
irritating  gastric  fluids.  Mathieu  advocates  evacuation  of  the  stag- 
nating liquid  once  a  day,  actually  washing  out  the  viscus  only  two  or 
three  times  a  week. 

Dilatation  due  to  stricture  of  the  pylorus  demands  a  surgical  ope- 
ration. When  the  stenosis  is  cicatricial,  forcible  dilatation  or  a  pyloro- 
plastic  operation  is  indicated  ;  when  the  obstruction  is  cancerous,  gastro- 
enterostomy is  the  best.  One  of  two  operations  may  be  resorted  to — 
gastro-enterostomy,  which  deals  only  with  the  obstruction,  or  a  partial 
gastrectomy,  which  removes  the  pylorus  and  a  part  of  the  stomach, 
thus  diminishing  the  size  of  the  dilated  organ.  Out  of  18  cases  of  gastro- 
enterostomy collected  by  Lowenstein  there  were  6  deaths  ;  in  21  cases 
of  resection  of  the  pylorus  there  were  7  deaths.  In  all  cases  of  dilata- 
tion particular  attention  should  be  paid  to  the  following  points  :  The 
food  should  contain  the  greatest  possible  nutriment  in  the  smallest 
bulk ;  it  should  be  finely  divided,  so  as  to  come  speedily  in  contact 
with  the  gastric  juice  and  leave  as  little  residuum  as  possible.  Meat- 
powder,  milk,  and  the  farinas  are  specially  useful. 

The  diet  should  consist  of  articles  which  are  least  likely  to  undergo 
fermentation.  On  this  account  sugar,  alcohol,  and  vinegar  should  be 
avoided.  The  muscular  action  of  the  stomach  should  be  increased  by 
the  use  of  strychnin,  ipecacuanha,  electricity,  massage,  etc. 

Antisepsis  of  the  stomach  should  be,  as  far  as  possible,  secured  by 
the  avoidance  of  fermentable  food  and  by  frequent  washings  of  the 
stomach.  Patients  soon  learn  to  carry  out  this  by  themselves,  and 
what  is  at  first  a  very  disagreeable  procedure  becomes  a  source  of 
great  comfort.  In  the  words  of  Ewald,  "  Lavage  is  the  sovereign 
remedy  for  dilatation." 

IV.    DISEASES   AND   INJURIES  OF  THE   INTESTINES. 

Examination  of  the  Intestines. — Inspection  may  give  us 
considerable  information.  A  solid  tumor,  such  as  a  carcinoma,  causes 
the  abdominal  wall  to  bulge  outward.  Obstruction  of  the  lower  por- 
tion of  the  small  intestine  is  often  attended  with  tympanites  and  pain  in 
the  umbilical  region  ;  that  is  to  say,  in  the  normal  position  of  the  bulk 
of  the  small  intestine.  Peristaltic  action  of  the  intestine  in  an  ex- 
aggerated degree  may  be  seen  through  the  abdominal  wall  when  there 
is  obstruction  and  the  intestine  is  making  strong  efforts  to  overcome 
that  obstruction.  General  distention  of  the  abdomen  and  tympanites 
form  a  very  unwelcome  sight  after  celiotomy,  and  stand  out  in  strong 
contrast  to  the  flat  abdomen  which  is  the  joy  and  pride  of  the  ab- 
dominal surgeon. 

By  palpation  we  ascertain  the  presence  of  tenderness.  A  dull 
diffused  pain  is  a  common  accompaniment  of  intestinal  catarrh ;  an 
acute  diffuse  pain  is  an  indication  of  general  peritonitis.  Tenderness  in 
the  right  iliac  fossa  is  a  characteristic  of  typhoid  fever,  appendicitis,  and 
intestinal  tuberculosis.  In  the  left  iliac  fossa  it  is  a  symptom  of  trouble 
in  the  descending  colon,  and  is  commonly  found  in  dysentery.  When 
tenderness  is  very  acute  and  shifting  about,  it  is  strongly  suggestive  of 
invagination  of  the  small  intestine. 


234  SURGICAL    DIAGNOSIS  AND    TKEATMENT. 

Having  settled  the  question  of  tenderness,  we  further  use  palpation 
to  search  for  tumors.  By  a  rotary  motion  of  the  abdominal  wall  over 
the  subjacent  structure  the  presence  of  tumors  can  be  detected  long 
before  they  can  be  recognized  by  inspection.  When  a  tumor  of  the 
intestine  is  felt  it  must  be  placed  in  one  of  three  classes:  i.  Fecal 
masses  or  scybala,  found  in  the  large  intestine  :  this  is  the  only  tumor 
which  retains  an  indentation.  2.  Tumors  of  the  intestine,  carcinoma, 
sarcoma,  etc. :  they  are  often  lobulated  and  of  firm  consistence.  In 
the  small  intestine  these  tumors  are  apt  to  change  their  location, 
while  in  the  large  intestine  they  are  more  fixed.  3.  Invagination  of 
one  portion  of  the  small  intestine  into  another  or  of  the  small  into  the 
large  intestine.  Tumors  of  this  character  are  round  and  smooth,  the 
pain  is  violent  and  comes  in  paroxysms.  The  other  indications  of 
intussusception  described  under  Acute  Intestinal  Obstruction  are  also 
present. 

Tumors  at  the  junction  of  the  transverse  with  the  descending  colon 
are  usually  difficult  to  detect,  for  they  lie  deep  and  are  liable  to  be 
confounded  with  tumors  of  the  kidney  or  spleen. 

Percussion. — In  health  every  part  of  the  intestine  gives  forth  a 
tympanitic  note,  the  pitch  varying  according  to  the  amount  of  fluid  or 
gaseous  contents.  The  size  of  the  intestine  cannot  be  accurately  deter- 
mined by  percussion,  nor  can  we  always  determine  the  boundary  be- 
tween colon  and  stomach  or  between  the  part  of  intestine  above  and 
that  below  a  constriction.  Tumors  of  the  intestine  may  grow  to  a 
considerable  size  and  yet  not  produce  dulness  on  percussion.  This 
diagnostic  measure  is  therefore  not  so  reliable  as  palpation.  Never- 
theless, there  are  cases  in  which  it  proves  very  satisfactory.  By  noting 
the  difference  in  pitch  between  the  stomach,  colon,  and  small  intestine 
in  the  normal  area  occupied  by  each  we  can  map  out  their  relative 
positions.  Tumors  which  in  light  percussion  elude  us  are  often 
detected  when  examined  by  "  deep  percussion  "  and  when  the  over- 
lying coils  of  intestine  are  pushed  aside.  Inflation  of  the  colon  with 
air  facilitates  percussion.  For  this  purpose  carbonic-acid  gas  has 
been  considered  preferable  to  air,  for  the  reason  that  its  irritating 
character  causes  closure  of  the  ilio-cecal  valve,  while  air  passes 
through  and  distends  the  small  intestine  as  well. 

The  phonendoscope  is  of  great  utility  in  examining  the  intestines. 
The  manner  of  using  it  has  been  described  in  Examination  of  the 
Abdomen. 

Diseases  of  the  Intestines. 

Cancer  of  the  intestine  is  a  disease  of  advanced  life.  Its  onset  is 
obscure.  Generally  there  is  constipation,  frequently  diarrhea,  always 
emaciation.  The  first  warning  of  anything  of  a  serious  nature  may  be 
obstruction  of  the  bowel.  The  growth  may  constitute  a  palpable 
tumor.  In  examining  for  it  the  patient  may  with  advantage  be  placed 
upon  his  hands  and  knees,  so  that  the  intestines  fall  toward  the  pal- 
pating hand  instead  of  away  from  it.  The  tumor  is  very  illusive.  One 
day  it  can  be  felt  with  the  greatest  ease,  the  next  you  may  search  for 
it  in  vain.     If  connected  with  the  small  intestine,  the  neoplasm  is  freely 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE   SYSTEM.       235 

movable  ;  if  in  the  colon,  it  is  firmly  fixed.  It  is  always  tender,  and  as 
it  increases  in  size  the  growth  is  in  the  direction  of  the  axis  of  the  intes- 
tine. Its  surface  is  lobulated  or  knotty,  and  it  is  incapable  of  receiving 
an  impression  like  a  fecal  tumor.  You  are  liable  to  fall  into  the  trap 
of  calling  it  sciatica  if  the  growth  is  in  the  lower  end  of  the  colon,  for 
the  sacral  region  is  the  part  to  which  the  patient  refers  his  pain. 

It  may  be  difficult  to  diagnosticate  the  portion  of  the  bowel  which 
is  the  seat  of  the  disease.  In  the  small  intestine  cancer,  as  a  rule, 
takes  an  annular  form,  and  on  this  account  the  leading  feature  is  sten- 
osis. The  symptoms  of  the  stenosis  will  vary  according  to  position. 
In  the  duodenum  we  cannot  always  undertake  to  say  which  portion  is 
affected.  The  first  portion  is  horizontal  in  direction,  is  almost  sur- 
rounded with  peritoneum,  is  the  most  movable,  and  lies  nearest  to  the 
abdominal  wall.  It  must  be  regarded  clinically  as  a  part  of  the  stomach 
and  partaking  of  the  diseases  of  the  stomach.  Hence  cancer  of  this 
portion  cannot  be  distinguished  from  cancer  of  the  pylorus. 

A  very  important  dividing-line  is  the  ampulla  of  Vater.  Stenosis 
below  this  point  is  characterized  by  a  permanent  backward  flow  of  bile 
and  pancreatic  juice  into  the  stomach.  Cancer  which  involves  the 
ampulla  has  characteristics  which  partake  of  the  symptoms  found  in 
both  the  first  and  third  portions. 

In  the  other  portions  of  the  small  intestine  the  presence  of  a  movable 
tumor  in  the  long  axis  of  the  bowel  will  afford  our  strongest  evidence. 
In  the  sigmoid  flexure  and  cecum  the  tumor  is  generally  distinct.  In 
all  cases  blood  is  not  infrequently  passed  by  the  bowels,  and  there  even 
may  be  masses  of  cancerous  tissue. 

The  rectum  is  the  portion  of  the  intestinal  tract  in  which  the  disease 
can  be  detected  with  the  greatest  degree  of  certainty.  One  of  the  ear- 
liest symptoms  is  pain  in  defecation.  Whenever  this  is  complained  of 
an  examination  of  the  rectum  should  be  made  as  a  matter  of  routine. 
As  the  disease  advances  the  pain  increases  and  is  more  or  less  constant. 
Blood  and  mucus  are  passed  in  the  stools,  and  in  many  cases  there  is 
morning  diarrhea. 

In  making  an  examination  of  the  rectum  the  patient  should  lie  upon 
the  left  side.  The  finger  is  vastly  superior  to  any  speculum.  The  sen- 
sation conveyed  to  the  finger  by  cancer  is  peculiar,  and  w^hen  once 
recognized  cannot  be  mistaken  for  anything  else.  If  the  growth  be 
epithelioma,  the  mucous  membrane  will  be  found  thickened,  firm,  and 
freely  movable,  at  least  before  the  disease  has  reached  an  advanced 
stage.  If  scirrhous  cancer  be  present,  hard  nodules  will  be  found 
involving  the  submucous  tissues,  and  later  infiltrating  the  other  tissues 
and  involving  the  glands,  the  liver,  and  other  organs. 

Two  diseases  are  likely  to  be  mistaken  for  cancer  of  the  rectum — 
simple  ulceration  with  inflammatory  thickening  and  syphilitic  ulceration 
with  or  without  stricture.  In  simple  ulceration  there  is  usually  a  his- 
tory of  dysentery  or  of  the  presence  of  foreign  bodies.  The  ulcer  is 
clean  cut,  and  has  the  same  kind  of  discharge  as  simple  ulceration  in 
other  parts  of  the  body.  There  is  no  infiltration  or  gland-involvement, 
and  the  growth  does  not  show  a  disposition  to  break  down. 

Syphilitic  deposit  w^ith  stricture  must  be  carefully  taken  into  con- 
sideration in  the  diagnosis,  as  it  is  a  common  source  of  error.     The 


236  SURGICAL    DIAGNOSIS  AND    7'REATMENT. 

history,  the  condition  of  the  throat,  the  skin,  the  scalp,  and  the  bones, 
will   usually  clear  up  any  doubt. 

Treatment. — Carcinoma  of  the  intestine  only  requires  surgical  inter- 
ference when  it  is  producing  obstruction.  In  the  duodenum  gastro- 
enterostomy is  in  many  cases  the  best  that  can  be  done.  In  other  por- 
tions of  the  small  intestine  resection  with  circular  enterorrhaj^hy  is  the 
operation  which  is  most  radical  and  easiest  of  performance.  Care  must 
be  taken  to  remove  the  corresponding  portion  of  mcsenteiy,  lest  the  can- 
cerous infiltration  should  spread  through  the  mesenteric  glands. 

Cancer  of  the  rectum  must  be  treated  according  to  the  extent  of 
the  disease.  When  the  highest  point  of  the  cancerous  mass  can  be 
reached  by  the  examining  finger,  and  there  is  no  involvement  of  the 
glands  or  neighboring  tissues,  excision  of  the  growth  should  be  under- 
taken. When  the  upper  limit  of  the  disease  cannot  be  reached,  or 
when  the  vagina,  the  prostate,  etc.  are  affected,  excision  of  the  rectum 
should  not  be  attempted.  < 

Operatioft. — For  several  days  before  the  operation  the  intestines 
should  be  well  emptied  by  purgatives  and  the  rectum  washed  out  with 
injections  of  boric-acid  solution.  The  patient  is  placed  in  the  lithotomy 
position,  and  a  final  flushing  given  to  the  rectum,  the  bladder  emptied, 
and  the  buttocks  elevated.  If  the  growth  is  small  and  freely  movable 
and  confined  to  the  posterior  wall  of  the  rectum,  it  will  be  sufficient  to 
dilate  the  sphincter,  draw  down  the  rectum,  excise  the  growth  by  a 
transverse  elliptical  incision,  and  close  the  wound  with  catgut  sutures 
or  pack  it  with  iodoform  gauze. 

The  great  majority  of  cases,  however,  will  require  a  more  extensive 
operation.  An  incision  is  made  from  the  anus  back  to  the  coccyx  in 
the  middle  line  or  a  little  to  the  left.  Crescentic  incisions,  one  on  each 
side,  are  made  to  surround  the  anus.  These  incisions  should  be 
through  the  skin  when  the  sphincter  ani  is  diseased,  through  the 
mucous  membrane  when  the  sphincter  is  healthy.  The  bowel  should 
then  be  dissected  up  quickly  behind,  and  bleeding  arrested  by  pressure- 
forceps.  In  front  of  the  rectum  the  dissection  must  be  slower,  as  there 
is  danger  of  getting  into  the  prostate  or  vagina.  When  the  bowel  has 
been  separated  well  above  the  disease,  cut  it  off  with  curved  scissors.  If 
in  this  procedure  the  peritoneum  has  been  opened  into,  it  must  be 
closed  with  sutures.  A  large  drainage-tube  guarded  with  a  chemisette 
\z  inserted  and  loosely  packed  with  iodoform  gauze.  Drawing  down 
the  divided  gut  and  suturing  it  is  no  longer  practised,  as  the  tension  is 
too  great  and  there  is  a  risk  of  retaining  secretions  which  interfere  with 
healing.  The  packing  can  be  removed  at  the  end  of  forty-eight  hours. 
Daily  injections  with  boracic-acid  solution  should  then  be  employed. 
W' hen  granulation  is  well  advanced  cicatricial  stenosis  must  be  guarded 
against  by  passing  a  full-sized  bougie  daily,  beginning  about  the  end 
of  the  second  week. 

Kraske's  operation  has  several  advantages  over  the  method  just 
described,  inasmuch  as  it  allows  more  complete  access  to  the  bowel. 
By  it  a  greater  extent  of  the  rectum  can  be  removed,  and  the  external 
wound  need  not  be  extensive.  The  incision  is  made  from  the  anus  to 
the  second  bone  of  the  sacrum  in  the  middle  line.  The  soft  parts  are 
then  separated  from  the  bone  on  the  left  side  until  the  edge  of  the 


INJURIES  AND   DISEASES    OF   THE   DIGESTIVE   SYSTEM.        237 

sacrum  is  freely  exposed.  The  coccyx  is  removed,  the  sacro-sciatic 
ligaments  divided,  and,  if  necessary,  the  left  side  of  the  sacrum  partly 
chiselled  away.  This  gives  complete  access  to  the  rectum.  The  pos- 
terior part  of  the  bowel  is  cut  open  down  to  the  sphincter,  and  then, 
by  transverse  incisions  above  and  below  the  cancerous  growth,  the 
diseased  portion  of  the  rectum  is  removed.  The  external  wound  is 
packed  with  iodoform  gauze,  and  the  rectum  irrigated  twice  a  day,  as 
in  other  operations. 

In  far-advanced  cases  of  cancer  of  the  rectum,  when  the  disease 
goes  high  above  the  point  which  can  be  reached  by  the  examining 
finger  and  causes  obstruction  of  the  bowel,  colostomy  is  the  proper 
treatment. 

Intestinal  Obstruction. — Intestinal  obstruction  may  be  con- 
sidered under  two  heads  : 

(i)  Acute  obstruction,  in  which  the  symptoms  come  on  suddenly 
without  any  previous  history  of  disease  ;    • 

(2)  Chronic  obstruction,  where  there  is  previous  intestinal  disease 
and  a  slow  gradation  from  partial  to  complete  occlusion. 

Acute  Intestinal  Obstruction. — The  almost  uniform  failure  to  cure 
acute  intestinal  obstruction  by  medical  treatment  has  led  the  profession 
to  look  to  surgery  as  the  only  hope  of  rescuing  a  class  of  cases  other- 
wise practically  hopeless.  The  operation  has  a  long  but  unfavorable 
history.  For  centuries  it  has  been  approved  and  as  strenuously  con- 
demned. Almost  uniform  disaster  has  attended  its  employment  until 
recent  years,  when  the  advancement  along  the  whole  line  of  abdominal 
surgery  has  thrown  new  light  upon  its  use  and  inspired  its  advocates 
with  new  hope. 

Acute  intestinal  obstruction  practically  exists  under  three  conditions  : 

1.  Intussusception; 

2.  Volvulus  ; 

3.  Strangulation  by  bands  or  through  apertures. 

By  intussusception  or  invagination  of  intestine  is  meant  a  prolapse 
of  a  part  of  a  bowel  into  the  lumen  of  the  adjoining  part.  One-third 
of  all  the  cases  of  obstruction  are  due  to  this  cause.  One  portion  of 
bowel  grasps — swallows,  as  it  were — the  portion  immediately  above  it. 
Grasping  the  bowel  as  if  it  were  food,  more  and  more  is  invaginated, 
until,  in  extreme  cases,  several  feet  of  bowel  may  be  involved.  The 
name  intussuscipicns  is  given  to  the  receiving  portion  of  intestine,  while 
the  part  invaginated  is  called  the  intussusccptuni. 

This  unnatural  condition  is  followed  by  serious  consequences  :  adhe- 
sions form  between  the  opposed  surfaces  of  peritoneum,  the  walls  be- 
come swollen  and  inflamed,  curving  of  the  intestines  by  dragging  of 
the  mesentery  is  produced,  intense  congestion  results,  followed  by 
discharge  of  blood  from  the  rectum  or  gangrene,  and  finally  complete 
obstruction. 

According  to  Senn,  sloughing  is  caused  by  obstruction  to  the  return 
of  venous  blood  by  constriction  at  the  neck  of  the  intussusception. 

Curiously  enough,  intussusception  is  very  commonly  found  in  the 
post-mortem  room,  one  body  in  four  showing  this  condition.  It  is  also 
believed  that  many  cases  right  themselves,  and  that  a  large  proportion 
of  cases  of  acute  colic  belong  to  this  class  (Greig  Smith). 


238  SUKGICAl.    DIAGXOSIS  AND    TREATMENT. 

The  most  common  situations  arc — (i)  in  the  small  bowel,  and  gen- 
erally the  lower  part  of  the  jejunum.  It  occurs  in  the  ileum  in  the 
proportion  of  one  case  to  four  in  the  former  class.  (2)  The  colon  may 
be  the  seat  of  an  intussusception  at  any  part  of  its  course,  but  it  is  by 
no  means  common,  and  when  it  does  occur  only  a  small  portion  of 
bowel  is  involved.  (3)  The  most  common  of  all  situations  is  the  ileo- 
cecal region,  and  here  it  may  be  produced  by  the  ileo-cecal  valve  form- 
ing the  apex  of  the  intussusception,  and,  passing  up  the  colon,  followed 
by  the  cecum  and  ileum,  or  the  ileum  may  pass  through  the  ileo-cecal 
valve  and  be  invaginated  up  the  colon. 

A  rare  and  complicated  variety  is  where  a  primary  invagination  of 
the  end  of  the  ileum  is  either  passed  through  the  valve  into  the  colon 
or  invaginated  into  the  colon  along  with  the  cecum  (Greig  Smith). 

By  volvulus  is  meant  an  occlusion  of  bowel  by  torsion  or  rotation 
round  its  axis  of  attachment.  This  may  be  caused  by  simple  twisting 
or  two  suitable  coils  may  be  intertwined. 

The  sigmoid  flexure  is  the  most  common  situation,  constituting  two- 
thirds  of  all  the  cases.  The  tendency  in  this  direction  is  increased  by 
the  shape  of  the  bowel,  the  length  and  loose  attachment  of  the  mesen- 
tery, and  the  tendency  of  the  bowel  to  become  overloaded  and  dis- 
placed by  collections  of  feces.  The  bowel  may  be  twisted  once,  twice, 
or  even  three  times  around  the  axis. 

Next  in  point  of  frequency  is  volvulus  of  the  cecum  or  cecum  and 
colon  adjoining.  Here  obstruction  is  easily  brought  about ;  even  an 
acute  flexure  of  the  cecum  is  sufficient  to  block  the  passage;  it  may  be 
produced  by  intertwining  of  the  small  intestine.  In  the  ascending  colon 
the  disease  is  rare  and  is  due  to  anatomical  abnormality.  In  the  cecum 
it  may  be  subacute  or  chronic. 

The  small  intestine  is  rarely  the  seat  of  volvulus.  An  old  hernia 
with  a  long  mesentery  may  be  a  predisposing  cause. 

Strangulation  by  tabids  or  through  apertures  is  internally  what  an 
ordinary  hernia  is  externally.  In  either  case  a  loop  of  bowel  is  con- 
stricted by  a  tight,  unyielding  opening,  obstructing  its  lumen  and  com- 
pressing its  vessels.  In  both  cases  strangulation  results,  producing 
symptoms  and  calling  for  treatment  almost  exactly  alike. 

Bands  of  organized  inflammatory  material,  the  so-called  "  peritoneal 
false  ligaments,"  occur  in  an  endless  variety  of  forms.  They  are  the 
result  of  old  attacks  of  peritonitis.  They  may  pass  from  coil  to  coil 
of  the  intestine,  or  from  organ  to  organ,  as  the  liver  and  uterus,  or 
from  the  intestine  to  the  abdominal  or  pelvic  wall.  Tubercular  glands 
may  form  their  starting-point,  and  the  bands  may  stretch  from  gland  to 
gland  in  the  mesentery,  or,  springing  from  one  side  of  a  gland,  may 
bend  around  the  intestine  and  become  attached  to  the  opposite  side  of 
the  same  gland.  They  may  be  round  or  flat,  short  or  long,  single  or 
multiple.  The  bowel  may  slip  under  a  band  when  it  is  short,  or  it  may 
be  caught  in  a  loop  or  twisted  when  the  band  is  long.  The  small  intes- 
tine, most  commonly  the  lower  part  of  the  ileum,  is  likely  to  be  the  seat 
of  the  strangulation. 

The  prog7iosis  of  acute  intestinal  obstruction  is  exceedingly  un- 
favorable. In  ordinary  strangulated  hernia  the  chances  for  recovery 
are  almost  nil,  yet  there  is  a  bare  chance,  for  gangrene  of  the  bowel 


INJURIES  AND  DISEASES   OF   THE   DIGESTIVE   SYSTEM.       239 

may  take  place  with  the  formation  of  a  false  anus.  In  strangulation 
by  bands  there  is  not  even  a  chance.  If  gangrene  takes  place,  there  is 
but  one  termination — death.  It  is  believed  that  spontaneous  recovery 
after  volvulus  is  unknown. 

Intussusception  in  a  very  small  proportion  of  cases  may  right  itself 
and  the  patient  recover,  but  such  fortunate  terminations  are  few  and  far 
between. 

The  diagnosis  of  acute  obstruction  is  of  the  utmost  importance,  and 
in  many  cases  exceedingly  difficult.  The  symptoms  are,  roughly  speak- 
ing, those  of  strangulated  hernia  in  an  aggravated  form.  The  abdom- 
inal pain  is  agonizing.  In  some  instances,  however,  it  is  not  severe,  and 
frequently  it  is  intermittent  in  character.  The  severity  of  the  pain  appears 
to  bear  a  direct  ratio  to  the  force  of  the  peristaltic  movements  ;  and  this 
explains  the  intermittent  character  of  the  suffering.  When  constric- 
tion takes  place,  the  bowel  makes  an  effort  to  overcome  it,  and  wave  after 
wave  of  peristaltic  movement  is  directed  against  the  obstruction.  The 
motions  grow  stronger  and  stronger,  and  the  pain  increases  in  seventy 
till  from  exhaustion  of  the  bowel-muscle  the  movement  ceases  and  the 
pain  subsides.  After  a  period  of  rest,  the  wall  of  the  intestine,  having 
regained  its  tone,  renews  its  fruitless  attack,  and  with  this  new  effort 
the  pain  returns  to  its  former  intensity.  It  may  be  like  severe  colic,  or 
it  may  convey  the  sensation  of  a  tight  band  around  the  abdomen.  Be- 
sides pain,  the  prominent  symptoms  are  vomiting,  constipation,  collapse, 
and  tympanites. 

Temperature  is  of  little  value  as  a  symptom.  It  is  usually  sub- 
normal, and  even  when  peritonitis  occurs  it  may  remain  subnormal  to 
the  end. 

Vomiting  is  one  of  the  early  and  most  important  symptoms,  and 
we  may  set  it  down  as  a  rule  that  the  higher  the  obstruction  the 
more  violent  is  the  vomiting.  At  first  the  ordinary  contents  of  the 
stomach  are  voided,  either  in  gushes  without  much  effort  or  with 
violent  retching.  Later  the  vomit  is  bile-stained,  then  of  a  dark, 
grumous  material,  the  so-called  coffee-grounds.  Finally,  fecal  mat- 
ter is  vomited  more  or  less  diluted.  This  requires  that  the  constric- 
tion should  not  be  higher  than  the  jejunum.  Constipation  is  of  the 
most  obstinate  and  insuperable  nature.  When  once  the  intestine 
below  the  seat  of  constriction  is  emptied,  absolutely  nothing  passes 
from  the  bowels,  except  in  certain  cases  of  intussusception,  when 
blood  may  escape. 

Local  meteorism  is  a  symptom  upon  which  von  Wahl  lays  great 
stress.  The  intestine  above  the  seat  of  obstruction  becomes  distended, 
and  the  enlargement  gradually  continues  along  the  course  of  the  con- 
stricted bowel.  The  peristaltic  action  is  also  increased,  and  both  the 
contour  of  the  bowel  and  its  peristaltic  movements  may  be  seen 
through  the  abdominal  wall. 

Rosenbach,  Rosin,  and  others  claim  that  in  complete  obstruction  of 
the  ileum  there  is  always  indican  in  the  urine.  When  the  obstruction 
is  in  the  colon  or  high  up  in  the  small  intestine,  this  reaction  is  not 
produced.  The  simplest  test  is  to  boil  a  small  quantity  of  the  urine  in 
a  test-tube  and  add  nitric  acid,  drop  by  drop.  The  urine  turns  red,  and 
throws  down  a  precipitate  of  a  similar  color.     On  shaking  a  violet- 


240  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

colored  foam  is  produced.  So  long  as  this  reaction  can  be  detected  in 
the  urine  Rosenbach  considers  the  case  one  of  great  gravity,  and  its 
continuance  after  an  operation  proves  that  the  obstruction  has  not  been 
relieved.  It  disappears  within  twenty-four  hours  after  the  relief  of 
obstruction.  The  fallacy  in  this  symptom  lies  in  the  fact  that  it  may 
exist  in  a  variety  of  morbid  conditions.' 

Diagnosis  from  Other  Diseases. — Every  case  of  abdominal  pain, 
and  especially  when  the  pain  is  attended  with  vomiting,  should  be 
closely  investigated  for  hernia.  The  ordinary  hernial  outlets  should 
one  by  one  be  examined,  for  strangulated  hernia  is  the  condition  most 
likely  to  be  mistaken  for  acute  obstruction. 

Appendicitis  probably  comes  next,  but  here  there  is  the  history  of 
localized  indanmiation,  fever  rising  to  and  not  above  ioi°  or  102°,  with 
great  tenderness  over  the  position  of  the  appendix,  and  possibly  the 
formation  of  a  tumor. 

Diagnosis  of  the  Locality  of  the  Obstruction. — For  diagnostic  pur- 
poses it  is  convenient  to  divide  the  intestine  into  three  portions : 

1.  TJie  Duodenum  and  Jejunum. — When  acute  obstruction  occurs 
at  the  duodenum  or  upper  portion  of  the  jejunum  the  first  indication  is 
sudden  and  intense  pain  at  the  epigastrium,  followed  by  violent  vomit- 
ing. This  vomiting  is  constant  until  the  obstruction  is  relieved  or  the 
patient  dies.  It  never  becomes  stercoraceous,  for  it  is  too  high  up  to 
contain  fecal  matter.  The  parts  above  the  constriction  have  a  tendency 
to  become  dilated,  the  parts  below  to  become  collapsed.  Hence  we 
often  find  the  stomach  dilated  and  tympanitic,  while  the  abdomen  below 
is  flat  and  contracted.  The  bulk  of  the  bowel  being  below  the  con- 
striction, flatus  and  feces  may  pass  naturally. 

2.  The  Ileum,  or  Lower  Part  of  the  Jejunum. — The  constriction 
being  much  lower  than  in  the  preceding,  accumulation  of  gas  is  a 
marked  symptom,  and  we  consequently  find  the  abdomen  becoming 
rapidly  distended.  Vomiting  does  not  come  on  so  suddenly,  but  it  is 
persistent  and  changes  in  its  character — first  normal  stomach-contents, 
next  bile,  and  lastly  fecal  matter.  The  pain  is  colicky,  paroxysmal  at 
the  beginning,  but  soon  becoming  persistent. 

3.  Colon  and  Sigmoid  Flexjire. — Here  the  symptoms  come  on  more 
slowly.  The  patient  can  often  point  out  the  seat  of  obstruction  by  the 
localized  pain.  Tympanites  is  a  very  marked  symptom  after  the  first 
few  days.  No  fecal  matter  or  flatus  passes  from  the  bowel  and  the 
rectum  is  empty. 

Is  it  possible  to  diagnose  the  variety  of  obstruction  ?  In  certain 
cases  it  is.  An  examination  by  the  rectum  will,  in  a  small  proportion 
of  cases,  discover  the  bowel  descending  in  intussusception.  This  form 
occurs  particularly  in  children.  The  pain  comes  in  waves,  gradually 
gaining  in  intensity  till  a  climax  is  reached,  when  it  for  a  time  subsides. 
Vomiting  in  this  form  is  not  so  characteristic  a  symptom  as  in  the 
other  varieties.  It  may  be  a  feature  from  the  outset  or  it  may  not 
appear  till  late  ;  it  may  be  severe  and  copious  or  slight  and  almost  pain- 
less, or  it  may  not  exist  at  all.  The  abdominal  wall  is  seldom  dis- 
tended ;  indeed,  it  may  even  be  retracted.  There  is  one  symptom, 
however,  which  is  valuable,  and   that  is  a   discharge  of  blood  from 

1  American   Year-Book  of  Medicine  and  Surgery,  1896. 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE   SYSTEM.        24I 

the  rectum,  which  is  often  associated  with  tenesmus  and  diarrhea.  If 
besides  these  a  tumor  can  be  found  by  palpation  through  the  parietes, 
we  have  about  all  the  evidence  we  can  obtain  that  the  case  is  one  of 
intussusception. 

So  rapid  is  the  progress  of  the  disease  that  death  may  take  place 
within  twenty-four  hours.  In  more  favorable  cases  the  fatal  event  is 
postponed  for  several  days  ;  in  those  still  more  favorable  the  condition 
may  become  chronic  and  last  for  several  weeks. 

In  volvulus  of  the  large  intestine  there  is  usually  a  previous  history 
of  constipation.  It  is  commonly  found  in  males  above  middle  life.  Its 
usual  situation  is  at  the  sigmoid  flexure.  The  pain  comes  on  suddenly, 
is  felt  at  the  hypogastrium  or  in  the  back  ;  constipation  is  marked  from 
the  first ;  vomiting  is  a  later  development  and  is  not  necessarily  severe. 
Feculent  vomiting  occurs  in  about  1 5  per  cent,  of  the  cases.  In  later 
stages  of  the  disease  there  is  tenderness  on  pressure. 

Volvulus  of  the  small  intestine  and  strangulation  by  bands  so  closely 
resemble  each  other  in  symptoms  that  it  is  probably  impossible  to 
distinguish  them.  In  both  the  pain  is  severe  and  continuous  from  the 
outset,  with  frequent  exacerbations,  and  is  felt  most  commonly  at  the 
umbilicus.  There  is  no  tenderness  on  pressure.  The  vomiting  begins 
early,  is  frequent,  copious,  and  becomes  stercoraceous  about  the  fourth 
day. 

In  the  following  table  I  have  tried  to  place  .side  by  side  the  diagnostic 
differences  in  the  three  forms  of  obstruction : 


Strangulation  by  Bands. 


Volvulus. 


Intussusception. 


Young  males. 


Age. 
Males  above  forty. 


Young  children. 


At   umbilicus ;    severe    from 
the  beginning. 


Pain. 
Hypogastrium      or      back ; 
comes  on  at  once,  but  not 
so  severe ;.  intermits. 


Prominent ;  comes  in  waves. 


Early,  frequent,  copious, 
stercoraceous,  fourth  or 
fifth  day. 


Vomiting. 
Late    or    not    at  all ;    never 
very  urgent ;  1 5  per  cent, 
of  cases  feculent. 


Very  variable  symptoms. 


Complete  from  first. 


Not    at    first    marked ;     no 
tumor. 


Constipation. 
From  first. 

Abdominal  Distention. 
Rapid  accumulation  of  gas, 
causing  great  distention ; 
no  tumor. 


Blood     from    bowels,    with 
tenesmus. 


Usually  absent ;  tumor  felt 
through  parietes  or  in  rec- 
tum. 


Die  about  the  fifth  day. 


Duration. 
Average  six  days. 


Twenty-four  hours  to  several 
days  or  weeks. 


Treatment. — Perhaps  no  condition  requires  more  promptness,  accu- 
racy, and  good  judgment  than  intestinal  obstruction.  Temporizing  in 
the  diagnosis  may  allow  the  only  chance  of  saving  the  patient  to  slip 


16 


242  SURGICAL    D/AGXOSIS  AND    TREATMENT. 

away.  Purgatives,  althouf^li  apparently  demanded,  may  produce  irre- 
parable injury.  If  medical  treatment  be  persisted  in  till  the  condition 
becomes  desperate,  no  amount  of  surgical  skill  can  make  amends  for 
an  opportunity  for  ever  lost.  As  regards  medical  treatment  little  need 
be  said.  When  we  consider  that  the  condition  is  analogous  to  stran- 
gulated hernia,  the  question  of  drugs  becomes  a  secondary  matter.  The 
chief  value  in  medical  treatment  is  the  rehef  of  the  distressing  symp- 
toms that  are  ever  present.  Vomiting  is  one  of  these.  Food  by  the 
mouth  is  not  only  useless,  but  positively  harmful.  Alimentation  must 
be  kept  up  by  rectal  enemata  of  beef-tea,  brandy,  and  other  easily- 
assimilated  nutriments.  When  the  vomiting  is  feculent  the  stomach 
should  be  washed  out  wath  mild  antiseptic  solutions,  such  as  salicylate 
of  soda.  This  greatly  relieves  the  patient's  discomfort  and,  according 
to  Jessett,  arrests  peristaltic  action.  For  the  relief  of  pain  and  the 
lessening  of  peristalsis  opium  in  small  and  repeated  doses  is  valuable. 
One  serious  objection  to  its  use,  however,  is  that  it  is  apt  to  mask  the 
xsymptoms,  and,  by  giving  a  feeling  of  false  security,  to  prevent  the  sur- 
geon from  making  an  early  diagnosis.  Enemata  or  aperients  are  dan- 
gerous, as  they  increase  the  peristaltic  action  of  the  bowels,  aggravate 
the  vomiting,  and  hasten  collapse. 

Surgical  Trcatnie7it. — Surgical  procedures  may  be  resorted  to  for 
two  objects — viz.  (i)  for  diagnosis,  and  (2)  for  relief  of  the  obstruction. 
It  is  not  discreet  to  advocate  exploratory  incisions  as  a  routine  prac- 
tice, but  when  delay  is  attended  with  such  disastrous  consequences  as 
often  happens  in  these  conditions,  if  ever  an  exploration  is  advisable  it 
is  here.  When  there  is  positive  evidence  of  acute  obstruction  due  to  a 
constriction,  operation  with  the  utmost  promptness  is  demanded,  for  we 
might  just  as  reasonably  treat  a  strangulated  hernia  by  the  expectant 
method  as  to  trust  to  medical  treatment  here.  The  diagnosis  should 
be  made,  if  possible,  and  the  operation  resorted  to,  before  fecal  vomiting 
and  prostration  have  set  in. 

Various  minor  procedures  have  been  employed  for  the  relief  of 
obstruction.     These  will  receive  brief  mention  : 

Evaaiation  of  the  StomacJi. — This  has  been  mentioned  as  a  valuable 
remedy  for  the  relief  of  stercoraceous  vomiting. 

Distention  of  the  Colon. — The  injection  of  fluid  into  the  colon  is  a 
favorite  remedy,  and  one  almost  instinctively  resorted  to.  Many  cases 
of  intussusception  have  been  relieved  by  this  method.  To  be  of  any 
use  it  must  be  employed  early,  before  adhesions  have  formed  or  obstruc- 
tion to  the  circulation  at  the  seat  of  the  stricture  has  taken  place.  The 
water  employed  should  have  a  temperature  of  105°  to  108*^  F.  and 
should  contain  a  small  proportion  (0.7  per  cent.)  of  common  salt.  The 
fountain  syringe  from  which  it  flows  should  be  held  at  a  height  of  four 
feet,  which  gives  a  pressure  of  about  two  pounds  to  the  inch.  The 
fluid  should  be  slowly  injected,  four  ounces  to  the  minute  (Martin  and 
Hare).  This  treatment  should  not  be  persisted  in  beyond  thirty  or 
forty  minutes,  and  in  case  of  failure  abdominal  section  should  be 
resorted  to  without  delay. 

Distention  with  hydrogen  gas  or  with  filtered  air  is  now  regarded 
with  more  favor  than  the  injection  of  fluid.  It  is  only  to  be  thought 
of  in  the  early  stage  of  intussusception  or  volvulus,  and   great  care 


INJURIES  AND  DISEASES   OF   THE  DIGESTIVE  SYSTEM.       243 

must  be  taken  lest  too  forcible  distention  produce  ov^erstretching  or 
rupture  of  the  bowel, 

Maniial  Exploration  of  the  Rectum. — In  children  a  digital  examina- 
tion may  reveal  an  intussusception  low  down.  The  introduction  of  the 
whole  hand  is  a  procedure  to  be  discouraged,  except  under  very  special 
circumstances.  It  is  not  warrantable,  except  when  the  patient  is  an  adult 
and  the  surgeon  is  possessed  of  a  small  and  slender  hand. 

Puncture  of  the  Intestine. — When  there  is  great  distention  of  the 
intestine  with  gas,  and  the  circumstances  are  such  that  no  more  suitable 
operation  can  be  resorted  to,  puncture  of  the  bowel  by  a  small  aspi- 
rating needle  affords  temporary  relief  It  is  needless  to  say  that  this 
treatment  is  unscientific  and  not  to  be  recommended. 

Taxis  and  Massage  of  the  Abdomen. — This  method  has  had  its 
ablest  advocate  in  Mr.  Jonathan  Hutchinson,  who  described  the  pro- 
cedure in  the  following  words :  "  The  first  point  in  abdominal  taxis  is 
the  full  u.se  of  an  anesthetic,  so  as  to  obliterate  all  muscular  resistance. 
Next  (the  bowels  and  bladder  being  supposed  to  be  empty)  the  surgeon 
will  forcibly  and  repeatedly  knead  the  abdomen,  pressing  the  contents 
vigorously  upward,  downward,  and  from  side  to  side.  The  patient  is 
now  to  be  turned  on  his  abdomen,  and  in  this  position  to  be  held  up 
by  four  strong  men  and  shaken  backward  and  forward.  This  done,  the 
trunk  is  to  be  held  uppermost,  and  shaking  again  practised  directly 
upward  and  downward ;  whilst  in  this  position  copious  enemata  are  to 
be  given.  The  whole  proceedings  are  to  be  carried  out  in  a  bond  fide 
and  energetic  manner.  It  is  not  to  be  merely  the  name  of  taxis,  but 
the  reality,  and  patience  and  persistence  are  to  be  exercised.  The 
inversion  of  the  body  and  succussion  in  this  position  are  on  no  account 
to  be  omitted,  for  they  are  possibly  the  most  important  of  all.  I  do  not 
think  that  I  ever  spend  less  than  a  half  or  three-quarters  of  an  hour  in 
the  procedure." 

It  may  well  be  questioned  whether  this  energetic  treatment  is  not 
attended  with  as  much  danger  as  a  carefully  executed  celiotomy,  while 
it  only  affords  a  haphazard  means  of  righting  an  obstruction. 

We  have  to  deal  with  a  disease  that  is  invariably  fatal  in  from 
twenty-four  hours  to  six  days.  Volvulus  has  never  been  known  to 
recover  under  medical  treatment.  Spontaneous  recovery  in  cases  of 
strangulation  by  bands  is  beyond  the  bounds  of  possibility,  and 
recovery  in  cases  of  intussusception  is  a  matter  of  the  merest  chance. 
Looking  at  the  matter  in  this  light,  the  choice  is  left  us  either  to  stand 
by  with  idle  hands  and  see  our  patient  die  or  to  make  the  attempt  to 
save  his  life  by  timely  operation. 

The  mortality  may  be  fairly  stated  at  95  per  cent,  in  cases  treated 
without  operation. 

The  statistics  of  celiotomy  for  obstruction  have  been  studied  by 
many  writers,  including  Schramm  in  Germany,  Delaporte  in  France, 
Treves  in  England,  and  Whithall,  Sands,  and  Ashhurst  in  America. 
Of  346  cases  collected  by  Ashhurst,  the  mortality  was  as  follows : 

Intussusception,  65  cases  ;  mortality,  75.4  per  cent. 

Volvulus,  29      "  "  71.4    "       " 

Strangulation  by  bands,  1 19      "  "  67.8    "       " 


244  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

In  the  aererrecrate  of  \a6  cases  from  all  causes  the  mortality  after  the 

111  •/- 

operation  was  69.3  per  cent.  We  thus  see  that  the  chances  m  favor  of 
operation  are  as  95  to  69.3,  or  a  saving  of  nearly  25  per  cent.  In 
Ashhurst's  earlier  statistics  he  found  the  mortality  to  be  67.6,  and 
argues  that,  contrary  to  the  history  of  most  operations,  the  gravity  of 
this  one  increases  rather  than  diminishes  as  it  is  more  often  resorted  to. 

It  must,  however,  be  remembered  that  statistics  of  this  character  are 
misleading.  The  difficulty  of  getting  the  results  of  unsuccessful  cases 
must  always  be  great.  The  operation  has  hitherto  been  resorted  to  in 
the  most  hopeless  cases,  and,  as  a  rule,  when  every  other  means  had 
failed  and  death  was  imminent.  With  increasing  confidence  and  dimin- 
ished fear  of  operating  it  is  likely  that  the  operation  will  be  resorted  to  at 
an  earlier  period  and  the  main  danger  wall  be  eliminated — the  danger 
of  delay.  An  early  resort  to  operation  might  confidently  be  expected 
to  bring  about  such  good  results  as  have  followed  the  early  use  of 
forceps  as  compared  with  ancient  practice,  or  the  success  which  fol- 
lows early  herniotomy.  Given  a  competent  operator,  cases  treated 
before  abdominal  distention  has  come  on,  before  the  bowel  has  become 
inflamed  or  gangrenous,  before  adhesions  have  formed,  before  the 
patient's  strength  has  become  exhausted,  would  it  be  too  much  to  say 
that  the  mortality  would  be  reduced  to  1 5  per  cent.,  as  predicted  by 
Dr.  Greig  Smith  ? 

Operations. — Having  decided  that  obstruction  exists,  the  course  to 
pursue,  as  a  rule,  would  be  as  follows  :  Distention  with  warm  water 
should  be  given  a  fair  trial,  provided  w^e  are  satisfied  that  the  obstruc- 
tion is  recent  and  there  are  no  firm  adhesions  nor  a  gangrenous 
bowel.  Some  prefer  hydrogen  gas  or  filtered  air.  The  advantage 
of  using  warm  water  is  that  in  the  event  of  failure  to  overcome 
the  obstruction  it  fulfils  another  indication  which  is  a  necessary 
preliminary  to  operation — /.  e.  it  washes  out  the  lower  portion  of 
the  intestinal  tract.  One  trial  only  of  this  method  should  be  em- 
ployed. If  there  is  a  tumor,  showing  the  probable  presence  of 
intussusception,  success  will  be  manifested  by  disappearance  of  the 
tumor.  In  some  cases  the  question  can  at  once  be  settled,  for  the 
tumor  remains  as  large  as  before,  occupying  its  original  position.  In 
such  an  event  we  would  better  proceed  to  operate  at  once,  without 
letting  the  patient  come  out  of  the  influence  of  the  anesthetic.  When 
there  is  still  doubt  as  to  whether  the  distention  has  been  successful  or 
not,  the  patient  should  be  allowed  to  regain  consciousness.  The  symp- 
toms will  soon  decide  the  question  beyond  doubt. 

EntC7'ostomy  (iuzspov,  the  intestine,  and  azo/ia,  a  mouth)  is  the 
formation  of  an  artificial  opening  in  the  intestine  by  which  the  contents 
can  be  discharged.  The  operation  has  by  long  usage  gone  under  the 
name  of  enterotomy  (evrspov,  the  intestine,  and  to/jltj,  an  incision). 
This  term  should  be  limited  to  the  making  of  an  incision  into  the 
bowel  as  for  the  removal  of  a  foreign  body. 

Enterotomy^  as  it  was  improperly  called,  was  first  performed 
by  Nelaton  on  a  patient  of  Trousseau's  about  the  time  the  great 
French  clinical  teacher  was  delivering  those  delightful  lectures  at  the 
Hotel  Dieu.  Nelaton  advocated  this  operation  in  cases  of  intestinal 
obstruction  w^iich  had  lasted  six  or  eight  days,  attended  with   fecal 


INJURIES  AND  DISEASES   OF   THE   DIGESTIVE   SYSTEM.       245 

vomiting  and  great  abdominal  distention.  Resorted  to  under  such 
desperate  circumstances  and  without  the  aid  of  modern  technique,  we 
need  not  wonder  that  the  operation  was  attended  with  such  indifferent 
success.  It  has  no  future,  for  it  will  be  employed  only  in  cases  which 
from  neglect  have  been  allowed  to  run  on  till  profound  collapse  has  left 
the  patient  in  such  a  condition  that  the  only  thing  possible  to  save  his 
life  is  to  draw  up  a  loop  of  intestine,  open  and  drain  it.  An  artificial 
opening  of  the  bowel  through  the  skin  must  always  place  the  patient 
in  a  pitiable  condition.  An  artificial  opening  from  one  part  of  the  intes- 
tine to  another  is  a  different  thing,  and  will  take  the  place  of  the  old 
operation. 

Enterostomy  is  a  very  simple  operation.  The  abdominal  wall  is 
divided  by  an  incision  one  and  a  half  to  three  inches  in  length  parallel 
to  and  a  little  above  Poupart's  ligament,  between  the  anterior  superior 
spine  of  the  ilium  and  the  epigastric  artery.  Stitch  the  parietal  peri- 
toneum to  the  skin  by  a  continuous  suture.  A  loop  of  distended 
bowel — which,  as  a  rule,  proves  to  be  some  part  of  the  lower  portion 
of  the  ilium — is  drawn  out  and  attached  by  sutures  to  the  abdominal 
wound.  If  the  case  is  not  very  urgent,  the  bowel  need  not  be  opened 
for  several  hours.  This  greatly  lessens  the  risk  of  infecting  the  peri- 
toneal cavity,  as  it  allows  adhesions  to  form  between  the  bowel  and  the 
abdominal  wound.  If  the  bowel  has  to  be  opened  at  once,  great  care 
should  be  observed  in  placing  the  sutures  so  as  to  shut  off  the  ab- 
dominal cavity.  A  portion  of  the  surface  of  the  bowel  about  the  size 
of  a  silver  quarter-dollar  can  be  secured  to  the  edge  of  the  wound  by 
fine  silk  sutures,  either  continuous  or  interrupted,  and  an  opening  made 
by  scissors  or  tenotomy-knife  large  enough  to  admit  the  finger.  This 
opening  must  be  kept  patent  by  placing  a  single  stitch  on  each  side  to 
connect  the  margin  of  the  intestinal  wound  with  that  of  the  parietal 
opening.  Having  established  the  artificial  anus,  we  can  utilize  it  in  four 
ways  : 

1.  We  can  allow  the  patient  to  rally  and  regain  strength,  performing 
a  radical  operation  later. 

2.  In  cases  where  the  obstruction  does  not  admit  of  removal,  as  in 
cancer,  the  opening  can  be  allowed  to  remain  permanently. 

3.  Under  fortunate  but  rare  circumstances  a  cure  has  been  effected 
by  enterostomy,  the  obstruction  being  removed  by  spontaneous  correc- 
tion of  the  mechanical  conditions  which  produced  it. 

4.  When  the  operation  has  been  performed  for  fecal  accumulation, 
the  fistula  may  be  closed  as  soon  as  it  shall  have  fulfilled  its  purpose. 

Celiotomy  for  Acute  Obstniction. — This  is  the  operation  which  deals 
radically  with  the  obstruction  and  promises  the  best  results.  If  possible, 
a  diagnosis  should  be  made  before  the  obstruction  has  lasted  twenty- 
four  hours. 

Preparation  of  the  Patient. — When  there  is  vomiting,  and  especially 
if  it  be  of  a  feculent  character,  the  stomach  should  be  washed  out 
with  a  5  per  cent,  solution  of  salicylate  of  soda.  The  bowels  also 
should  be  emptied  by  a  warm-water  injection,  and  an  enema  of  brandy 
and  beef-tea  given  just  before  the  operation.  The  skin  over  the  abdo- 
men, having  been  washed  with  warm  water  and  green  soap,  is  next 
cleansed  with  ether  or  turpentine,  and  lastly  with  corrosive-sublimate 


246  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

solution,  I  :  2(XX).  Chloroform  is  the  best  anesthetic,  as  it  is  attended 
with  more  placid  breathing  and  there  is  less  venous  congestion  than 
when  ether  is  administered.  In  some  cases  the  patients  are  so  deeply 
collapsed  that  general  anesthesia  cannot  be  borne.  The  injection  of 
cocain  along  the  line  of  incision  is  then  the  best  means  of  making  the 
operation  painless,  and  the  most  that  can  be  accomplished  is  the  forma- 
tion of  an  artificial  opening  in  the  intestine,  as  already  described  under 
Enterostomy. 

The  Iticision. — For  most  purposes  a  median  incision  midway  between 
the  umbilicus  and  pubes  will  answer  best.  It  should  be  long  enough  to 
admit  three  fingers,  and  can  be  extended  up  or  down  as  required  by 
dividing  the  parietes  with  strong  scissors.  It  may  be  set  down  as  a 
rule  that  all  parts  of  an  intestine  above  a  constriction  are  distended,  all 
parts  below  are  collapsed.  The  fingers  inserted  into  the  wound  should 
first  search  for  the  cecum.  Distention  at  this  portion  of  the  intestine 
means  that  the  colon,  sigmoid  flexure,  or  rectum  is  the  seat  of  obstruc- 
tion. Collapse  here  is  an  indication  that  the  obstruction  is  in  some  part 
of  the  small  intestine,  the  ileo-cecal  valve,  or  higher  up  (Jessett).  The 
abdominal  incision  should  be  extended  as  may  be  necessary  ;  coils  of 
intestine  should  be  allowed  to  escape,  care  being  taken  to  keep  them 
well  protected  by  cloths  or  flat  sponges  wTung  out  of  hot  water.  If 
the  search  in  the  neighborhood  of  the  cecum  has  been  fruitless,  the 
sigmoid  flexure  should  next  be  examined,  for  in  nine  cases  out  of  ten 
the  obstruction  will  be  found  in  the  lower  half  of  the  abdomen  and  in 
one  or  other  inguinal  region.  Still  failing  to  find  the  constriction,  a 
systematic  search  is  to  be  made  as  follows  :  Pick  up  a  loop  and,  draw- 
ing it  out  so  that  it  can  be  held  by  an  assistant,  examine  it  in  one 
direction ;  observe  whether  distention  and  congestion  increase  as  you 
pass  along  its  course.  If  so,  you  are  getting  nearer  and  nearer  the 
point  sought  for ;  but  if  the  bowel  becomes  more  healthy,  push  the 
loop  back  and  continue  your  search  in  the  opposite  direction. 

Once  the  cause  is  found,  its  removal  may  be  attended  with  some 
difficulty.  Bands  may  be  divided  between  ligatures,  an  opening  may 
be  enlarged,  as  in  the  case  of  an  ordinary  hernia,  a  volvulus  may  be 
untwisted,  an  intussusception  drawn  out.  When  the  operation  has 
been  resorted  to  before  adhesions  have  formed  or  gangrene  has  com- 
menced these  methods  of  relief  are  possible ;  but,  unfortunately,  com- 
plications and  difficulties  must  often  be  encountered,  and  these  we  shall 
consider  under  the  different  forms  of  obstruction. 

Intussusception. — Interference  with  circulation  at  the  constriction  sets 
in  at  an  early  period,  and  consequently  congestion  and  edema  are 
serious  obstacles  to  reduction.  An  analogous  condition  is  found  in 
paraphimosis.  The  swelling  and  edema  must  be  removed  before  the 
telescoped  portion  of  bowel  can  be  relieved.  Three  maneuvers  may  be 
successively  tried : 

1.  Apply  steady  pressure  to  the  intussusception,  and  when  the 
swelling  disappears  draw  gently  down  upon  the  neck  of  the  intussus- 
ceptum. 

2.  Pass  a  director  around  between  the  intussuscipiens  and  the 
intussusceptum,  and  very  gently  break  down  any  adhesions  that  may 
have  formed. 


INJURIES  AND   DISEASES   OF   THE  DIGESTIVE   SYSTEM.        247 

3.  Failing  in  both  of  the  above  methods,  the  bowel  may  be  inflated 
per  rectum  with  water  or  hydrogen  gas,  aided  by  traction  and  manipu- 
lation. 

When  invagination  has  been  relieved  by  one  or  other  of  these 
methods  the  bowel  must  be  carefully  examined :  slight  rents  in  its  peri- 
toneal coat  should  be  closed  with  Lembert  sutures  of  fine  silk  ;  abrasions 
and  gangrenous  spots  should  be  protected  by  omental  grafts. 

It  often  happens  that  adhesions  have  become  so  firm  that  they 
cannot  be  separated,  or  the  bowel  has  been  so  long  strangulated  that 
it  has  become  gangrenous.  For  the  first  of  these  complications  we 
resort  to  intestinal  anastomosis,  for  the  second  to  resection  of  the 
gangrenous  portion  of  bowel,  intussusception  and  all. 

Intestinal  Anastomosis. — Where  rapids  occur  in  the  St.  Lawrence 
River  the  obstacles  to  navigation  have  been  overcome  by  connecting 
the  river  above  and  below  the  rapids  by  means  of  a  canal.  In  like 
manner  we  get  rid  of  intestinal  obstruction  by  inosculating  a  loop  of 
intestine  above  to  a  loop  below  the  stricture,  and  thus  compelling  the 
intestinal  contents  to  take  a  shorter  course,  by  which  they  avoid  the 
portion  of  bowel  which  contains  the  obstruction.  This  idea  was  first 
suggested  by  Maisonneuve.  Billroth  and  Von  Hacker  also  gave  it 
considerable  study,  but  the  operations  were  never  attended  with  satis- 
factory results  until  Senn  designed  and  carried  out  the  method  of 
forming  anastomosis  with  decalcified  bone-plates.  As  regards  the 
indications  for  the  operation,  Prof  Senn  has  arrived  at  the  following 
conclusions:  "  i.  If  the  external  surface  of  the  bowel  presents  evi- 
dences of  gangrene,  disinvagination  should  not  be  attempted,  and  in 
such  cases  resection  is  absolutely  indicated.  2.  The  resection  under 
such  circumstances  should  always  include  the  whole  intussusceptum, 
but  only  so  much  of  the  intussuscipiens  as  is  threatened  by  gangrene. 
3.  If  the  continuity  of  the  bowel  cannot  be  restored  by  circular  sutur- 
ing, either  on  account  of  the  difference  in  size  of  the  lumen  of  the 
resected  ends  or  of  inflammatory  softening,  the  same  object  is  attained 
in  an  equally  satisfactory  manner,  and  more  safely,  by  lateral  implanta- 
tion or  intestinal  anastomosis.  4.  If  the  invagination  is  not  extensive, 
but  irreducible,  and  the  bowel  presents  no  sign  of  gangrene,  the  ob- 
struction should  be  allowed  to  remain,  and  the  continuity  of  the  intes- 
tinal canal  restored  by  making  an  anastomotic  opening  between  the 
bowel  above  and  below  the  invagination  by  the  use  of  perforated 
decalcified  bone-plates.  5.  If  the  invagination  is  extensive,  irreducible, 
and  the  bowel  presents  no  indications  of  gangrene  externally,  the 
intussusceptum  should  be  made  accessible  through  an  incision  below 
the  neck  of  the  intussuscipiens,  and  resected  after  securing  the  stump 
with  an  elastic  ligature,  after  which  the  obstruction  is  permanently 
excluded  by  an  intestinal  anastomosis.  6.  In  irreducible  colico-rectal 
invagination,  or  when  this  form  of  invagination  has  been  caused  by  a 
malignant  tumor,  the  intussusceptum  should  be  drawn  downward  and 
removed  by  the  operation  devised  by  Mikulicz." 

Manner  of  Using  Bone-plates  {¥\g.  106). — Having  selected  the  two 
loops  which  are  to  be  united,  (i)  shut  off  the  remainder  of  the  bowel 
from  the  part  to  be  operated  upon  by  clamps,  rubber  bands,  or  strips 
of  iodoform  gauze,  two  for  each  loop.     (2)  Make  in  each  loop  a  longi- 


248 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


tudinal  incision  on  the  convex  side  of  the  intestine  at  the  part  most  dis- 
tant from  the  mesentery.    This  incision  should  be  two  to  two  and  a  lialf 
inches  in  length.     Allow  the  contents  of  the  loop  to  escape  and  wash 
with  sterilized  warm  water.    (3) 
Slip  a  bone-plate  into  each  in- 
cision.    The  lateral  threads  are 
made  to  perforate  all  the  coats 
of  the  bowel ;  the  end  threads 
are  left  lying  in  the  angles  of 
the  wound  (Fig.  107).     (4)  Tie 
the  threads  and  allow  the  knots 
to  lie  between  the  serous  sur- 
faces.   (5)  Additional  security  is 
gained  by  inserting  Lembert  su- 


FlG.  106. — Senn's  decalcified  bone- 
plate. 


Fig.  107.  —  Ileo-colostomy  with  decalcified 
bone-plates,  showing  plates  in  position,  one  in 
the  ileum,  the  other  in  the  colon:  a, a, a,  lateral 
or  fixation-sutures  passed  through  the  margins  of 
the  wound,  a  to  be  tied  to  a  ;  b,  b,  b',  b',  end-  or  ap- 
position-sutures, to  be  tied  b  lo  b  and  b'  to  b';  c,  pos- 
terior or  sero-muscular  sutures  (Keen  and  White). 


tures  at  intervals  to  unite  the  serous  surfaces  around  the  margins  of  the 
plates  (Fig.  108).  Scratching  the  serous  surfaces  with  the  point  of  a 
needle  may  hasten  their  union  when  brought  into  apposition.  This, 
however,  is  of  doubtful  value.  Serous  surfaces  readily  unite  without 
this,  and  the  dangers  of  infection  through  even  a  slight  scratch  should 
not  be  overlooked. 

Abbe  of  New  York  objected  to  Senn's  bone-plates  on  account  of 
the  difficulty  of  getting  plates  of  bone  large  enough  for  use  in  the 
human  subject,  the  trouble  required  for  preparing  them,  and  their 
tendency  to  warp  and  bend,  and  has  devised  rings  composed  of  several 
strands  of  thick  catgut  around  which  are  wound  spirally  other  threads 
of  the  same  material. 

Plates  composed  of  raw  turnip  or  potato  have  been  used. 

Murphy  of  Chicago  has  invented  a  very  ingenious  and  easily 
applied  "button,"  which  can  be  utilized  with  great  rapidity  and  is 
suitable  for  any  operation  to  which  bone-plates  can  be  applied.     The 


INJURIES  AND  DISEASES   OF  THE   DIGESTIVE   SYSTEM.       249 


»-'"^' 

^ 


Fig.  108. — Showing  the  anterior  continued  sero-muscular  suture  as  the  final  step  in  ileo- 
colostomy  (Keen  and  White). 


Fig.  109. — Murphy's  but- 
ton (enlarged) :  A,  open  ;  B, 
closed. 


Closed.  Open. 

Fig.  I  id. — Oblong  Murphy  button. 


Fig.  III. — Method  of  applying  purse-string  suture  in 
using  the  Murphy  button. 


Fig.  112. — End-to-end  approximation,  button  in  position. 


250  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

following  objections  have  been  urged  against  it :  The  serous  surfaces 
brought  into  apposition  are  too  limited  in  extent  to  afford  safety ;  the 
button  required  for  the  small  intestine  is  of  so  small  a  size  that  a  con- 
striction at  the  seat  of  operation  is  a  common  result,  and  the  button  is 
not  always  passed  in  the  alvine  evacuations.     Notwithstanding  these 


Fig.  113. — Showing  incision  into  the  intussuscipiens,  the  intussusceptum  being  seized  by 
volsellum  forceps  and  cut  across  with  scissors  (first  stage)  (after  Jessett). 


Fig.  114. — Showing  intussusceptum  detached,  and  the  divided  end  of  intestine  sutured 
(second  stage)  (after  Jessett). 


Fig.  115. — Showing  incision  in  the  intussuscipiens  closed,  and  the  neck  of  the  intussusceptum 
united  at  end  with  sutures  (final  stage)  (after  Jessett). 

criticisms  most  excellent  results  have  been  obtained  by  this  method, 
and  the  "  button  "  is  gaining  in  popularity.  The  method  of  using  the 
button  is  shown  in  Figs.  109-112.  In  each  loop  of  intestine  to  be 
united  a  purse-string  suture  is  placed,  as  shown  in  Fig.  in.  The 
intestine  is  then  opened,  and  one  half  of  the  button  is  grasped  in  a 
pair   of   hemostatic  forceps    inserted   into   the    opening.      The    purse- 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE   SYSTEM.       25  I 

string  suture  is  then  tied,  care  being  taken  to  include  all  the  free 
edges  of  the  incision,  so  that  they  will  come  between  the  halves  of 
the  button.  The  other  loop  of  intestine  is  dealt  with  in  a  similar 
manner,  and  the  sections  of  the  button  are  then  clasped  together. 
The  peritoneal  surfaces  unite,  and  by  the  constant  pressure  exerted 
by  the  spring  of  the  button  the  compressed  parts  slough,  allowing 
the  button  to  pass  per  anmti  in  ten  or  twelve  days.  The  operation 
has  a  wide  application,  and  can  be  used  for  lateral  anastomosis,  end- 
to-end  anastomosis,  gastro-enterostomy,  enterectomy,  pylorectomy, 
and  cholecystenterostomy. 

Jessett  has  devised  an  operation  which  may  prove  useful  from  its 
simplicity.  He  makes  a  longitudinal  opening  into  the  intestine  on  the 
side  farthest  from  the  mesentery,  directly  over  the  intussusception, 
about  one  and  a  half  inches  long.  Through  this  opening  he  exposes 
the  invaginated  portion,  and  with  scissors  cuts  it  off  close  to  its  origin 
(Figs.  113,  1 14,  1 15),  and,  seizing  the  distal  part  with  volsellum  forceps, 
draws  it  out  of  the  intussuscepiens,  ligating  any  vessels  that  bleed. 
The  cut  ends  are  next  stitched  together  with  a  few  interrupted  sutures, 
the  stump  dropped  back  into  the  intestine,  and  the  opening  through 
which  it  was  withdrawn  closed  with  a  double  row  of  quilt  sutures.  The 
advantages  claimed  for  this  operation  are  that  it  is  much  less  dangerous 
than  resection  or  anastomosis,  and  that  it  is  certainly  preferable  to  an 
artificial  anus. 

It  may  happen  that  the  surgeon  is  so  situated  that  he  must  operate 
without  any  of  the  artificial  aids  just  mentioned,  and  some  surgeons 
who  are  expert  in  the  use  of  the  needle  prefer  the  old  method.  Abbe 
has  described  a  procedure  by  simple  incision  and  suture  which  in  the 
hands  of  expert  operators  gives  good  results : 

I.  The  two  portions  of  bowel  which  are  to  be  united  are  placed  side 
by  side  (Fig.   1 16). 


Fig.  116. — Suturing  intestines  in  apposition         FiG.  117.— Showing  the  four-inch  incision  and 
before  incision  (Abbe).  the  sewing  of  the  edges  (Abbe). 

2.  Two  rows  of  continuous  Lembert  sutures  a  quarter  of  an  inch 
apart  and  an  inch  longer  than  the  necessary  incision  are  applied  as 
in  Fig.  117,  and  each  thread  left  with  its  needle  at  the  end  of  the  line 
of  suture. 

3.  The  bowel  is  opened  parallel  to  and  at  a  distance  of  a  quarter  of 
an  inch  from  this  line  of  sutures.  The  length  of  the  incision  is  four 
inches,  and  both  rows  of  sutures  are  at  one  side  of  the  incision. 
Hemostatic  forceps  are  applied  to  bleeding  points  and  left  there  tem- 
porarily.    The  opposite  portion  of  the  intestine  is  similarly  opened. 


252  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

4.  The  two  adjacent  cut  edges  are  united  by  an  overhand  continuous 
suture,  the  mucous  and  serous  coats  being  included.  As  this  arrests 
the  hemorrhage,  the  forceps  can  be  removed  as  they  are  reached.  The 
other  free  edges  are  similarly  stitched. 

5.  The  openings  are  now  approximated  and  the  two  serous  surfaces 
brought  toeethcr.  The  needles  left  at  the  end  of  the  first  double  suture 
are  now  used  to  apply  a  similar  double  line  to  the  parts  last  approxi- 
mated, and  thus  the  whole  circumference  of  the  four-inch  opening  is 
securely  closed. 

Besides  intussusception,  intestinal  anastomosis  is  indicated  in — 

1.  Volvulus  ; 

2.  In  inoperable  carcinoma  if  the  disease  is  located  high  enough 

up  in  the  colon  to  admit  of  an  opening  being  made  below  it ; 

3.  Cicatricial  stenosis  of  the  intestine. 

Resection  of  Intestine  {Enterectomy). — This  operation  is  indicated  in 
all  cases  w-here  a  portion  of  the  bowel  is  gangrenous,  or  when  the 
intestine  is  the  seat  of  a  malignant  tumor  and  it  is  possible  to  remove 
the  disease  completely,  or  in  the  case  of  a  benign  tumor  which  cannot 
be  removed  by  enterotomy.  Any  length  of  bowel  from  a  few  inches  to 
three  or  four  feet  may  be  resected,  but  beyond  this  latter  limit  it  is  not 
safe  to  go,  for  in  case  of  recovery  the  patient  is  almost  sure  to  suffer 
from  want  of  nutrition,  and  he  gradually  wastes  away. 

Operation. —  i.  Draw  the  loop  of  intestine  to  be  resected  well  out  of 
the  abdominal  wound.  At  the  upper  and  lower  limits  of  the  segment 
perforate  the  mesentery  close  to  the  bowel,  and  pass  a  piece  of  rubber 
tubing  or  strip  of  iodoform  gauze  through  each  opening,  squeeze  out 
the  contents  of  the  segment,  and  tie  the  tubes  or  gauze  sufficiently 
tight  to  occlude  the  bowel.  Place  flat  sponges  or  sterilized  gauze 
pads  beneath  the  segment,  so  as  to  protect  the  remaining  abdominal 
contents. 

2.  Tie  off  the  mesentery'  in  small  sections  with  fine  silk  ligatures 
close  to  the  intestine,  divide  the  bowel  with  scissors  or  knife,  making 
sure  that  you  are  cutting  beyond  diseased  tissue.  Wash  out  the  lumen 
of  each  divided  portion  with  warm  sterilized  water. 

3.  The  divided  ends  are  approximated  in  either  of  the  following 
ways  : 

(a)  By  lateral  anastomosis,  the  ends  being  turned  in  and  sutured, 
and  the  remaining  steps  as  in  Abbe's  method. 

{B)  End-to-end  anastomosis.  One  continuous  suture  through 
mucous  membrane  only,  and  the  serous  coat  stitched  with  Lembert's 
suture. 

For  end-to-end  anastomosis  Murphy's  button  is  very  convenient 
and  quickly  applied,  and,  if  the  part  resected  is  a  portion  of  the 
colon  and  the  large-sized  button  is  employed,  there  cannot  be  any 
of  the  objections  which  are  urged  against  its  employment  else- 
where. 

4.  The  mesenter}'  may  be  treated  by  excising  a  V-shaped  portion  or 
by  folding  the  redundant  portion  upon  itself  and  stitching  it  at  its  free 
edge. 

The  after-treatment  of  resection  consists  merely  in  feeding  the 
patient  by  rectal  enemata  for  the  first  week.     Nothing  should  be  given 


INJURIES  AND   DISEASES    OF   THE   DIGESTIVE   SYSTEM.        253 

by  the  stomach  except  Hght  liquid  diet,  and  for  the  first  twenty-four 
hours  small  pieces  of  ice. 

Volvulus. — The  occurrence  of  a  twist  in  the  bowel  is  soon  followed 
by  great  distention,  peritonitis,  and  firm  adhesions.  If  we  remember 
that  when  the  peritoneal  surfaces  are  placed  in  close  apposition  there 
is  thrown  out,  even  by  the  end  of  the  first  hour,  a  thick  coating  of 
coagulable  lymph,  we  can  readily  understand  that  adhesions  soon 
become  so  firm  that  separation  of  them  is  out  of  the  question.  The 
bowel  may  be  simply  twisted  upon  itself  or  one  coil  may  be  intertwined 
with  another.  Strangulation  in  such  cases  quickly  comes  on,  and 
gangrene  is  inevitable.  Having  exposed  the  volvulus,  an  attempt  should 
be  made  to  straighten  out  the  twisted  portion  ;  if  this  cannot  be  done, 
the  distended  bowel  should  be  pulled  out,  opened  above  the  con- 
striction, and  emptied.  A  second  attempt  should  then  be  made  at 
reduction.  If  this  fails,  the  safest  procedure  is  to  make  an  artificial 
anus.  Resection  is  not  advisable,  as  the  extent  of  the  volvulus  is 
likely  to  include  a  considerable  part  of  the  intestine.  The  cases  in 
which  only  a  small  portion  of  the  intestine  is  involved  are  usually 
amenable  to  reduction. 

Strangulation  by  Bands. — As  a  rule,  it  is  a  simple  matter  to  get  rid 
of  a  band  when  once  it  is  reached.  A  ligature  should  be  placed  at 
each  extremity  of  the  band  as  close  to  its  attachment  as  possible  and 
the  band  divided.  One  point  should  be  guarded  against,  and  that  is 
the  possibility  of  a  second  band.  It  has  happened  more  than  once  that 
the  successful  removal  of  one  band  has  not  effected  a  cure,  owing  to 
the  existence  of  a  second  band,  which,  unnoticed  at  the  time  of  opera- 
tion, caused  death  by  strangulation  of  the  bowel  at  a  later  period. 

Meckel's  diverticulum,  a  common  cause  of  strangulation,  must  be 
dealt  with  in  the  same  manner,  care  being  taken  not  to  mistake  it  for 
bowel,  and  using  care  in  disinfecting  the  pervious  ends  when  divided. 
When  the  diverticulum  is  pervious  its  mucous  membrane  should  be 
turned  inward  and  its  fibrous  coat  stitched  on  the  outside. 

After  the  obstruction  has  been  relieved  by  any  of  the  methods  just 
described  the  remaining  steps  of  the  operation  are  conducted  on  the 
same  principles  as  celiotomy  for  any  purpose.  The  toilet  of  the  peri- 
toneum requires  due  attention.  The  abdominal  wound  should  be  care- 
fully approximated,  drainage  employed  when  demanded,  asepsis  adhered 
to  throughout,  and  the  patient  kept  in  bed  long  enough  to  allow  a  firm 
cicatrix,  and  thus  guard  against  a  subsequent  ventral  hernia. 

Chronic  Intestinal  Obstruction. — In  this  variety  the  intestine 
becomes  gradually  encroached  upon  and  the  lumen  narrowed.  At 
any  time  the  occlusion  may  become  complete,  and  then  the  case  is 
practically  one  of  acute  obstruction.  Chronic  obstruction  may  be 
produced  by — 

I.  Stricture  of  the  intestine,  cicatricial  or  malignant.  A  cicatricial 
stricture  is,  in  the  majority  of  cases,  the  result  of  the  healing  of  an 
ulcer  in  the  wall  of  the  intestine.  Much  depends  upon  the  size  of  the 
ulcer  and  upon  its  shape.  If  the  ulcerative  process  extends  along  the 
course  of  the  gut,  contraction  is  likely  to  be  slight ;  if,  on  the  other 
hand,  the  ulcer  is  annular,  the  lumen  is  greatly  lessened  and  may 
become  entirely  occluded.     Strange  as  it  may  appear,  the  large  bowel 


254  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

is  affected  six  times  as  frequently  as  the  small  intestine  (Treves). 
When  the  small  bowel  is  affected  it  is  generally  the  middle  and  lower 
end  of  the  ileum. 

Malignant  stricture  is  almost  always  cancerous  and  of  the  cylindrical 
epithelial  variety  (cylindroma).  It  has  a  tendency  to  encircle  the  gut, 
and  thus  constriction  is  more  readily  produced.  It  rarely  occurs  in 
the  small  intestine.  Of  43  cases  tabulated  by  Jessett,  the  small  intes- 
tine was  the  seat  of  the  disease  in  only  i  instance,  the  rectum  in  20, 
the  sigmoid  flexure  in  10,  and  other  parts  of  the  colon  in  12.  This 
would  indicate  that  the  nearer  the  anus  the  greater  the  liability  to 
malignant  stricture. 

2.  Benign  growths  affecting  the  wall  of  the  intestine  may  cause 
obstruction,  but  these  are  rare.  They  are  such  growths  as  adenomata, 
fibromata,  myomata,  fatty  and  cystic  tumors. 

3.  Foreign  bodies  obstructing  the  lumen  of  the  bowel.  Among 
these  are  classed  gall-stones,  which  may  grow  to  sufficient  size  to 
cause  obstruction,  bodies  swallow^ed  and  becoming  aggregated,  small 
polypi,  and  enteroliths. 

4.  Tumors  outside  of  the  intestine,  but  pressing  upon  the  gut  and 
obstructing  its  lumen. 

5.  Fecal  accumulations. 

6.  Paresis  of  the  intestinal  wall.  This  form  is  found  in  connection 
with  peritonitis  following  celiotomies.  There  is  really  no  occlusion  of 
the  bowel,  but  the  peristaltic  action  is  completely  arrested  and  ga.ses 
are  retained,  producing  great  abdominal  distention  and  discomfort. 
Sometimes  paresis  results  from  reflex  action,  as  in  cases  reported  by 
Pitt  and  Jessett. 

7.  Adhesions  following  celiotomy  or  hysterectomy.  One  of  the 
most  annoying  distant  results  of  operations  on  the  abdominal  or 
pelvic  organs  is  the  occurrence  of  intestinal  obstruction.  If  an 
abraded  surface  on  the  bowel  comes  in  contact  with  the  parietal 
wound  or  any  serous  surface,  an  adhesion  is  likely  to  take  place  at 
that  point,  which  gives  trouble  sooner  or  later.  Experience  goes  to 
show  that  this  occurs  more  readily  in  suppurative  cases.  Two  very^ 
practical  points  should  therefore  be  borne  in  mind  in  abdominal  opera- 
tions— namely,  to  spread  the  omentum  out  carefully  over  the  intestine 
and  to  avert  suppuration  by  the  most  scrupulous  asepsis.  These  ob- 
structions sometimes  prove  fatal  directly,  or  they  may  necessitate  the 
opening  of  the  abdominal  cavity  for  their  relief  It  is  a  statistical  fact 
that  these  secondary  operations  are  followed  by  a  large  proportion  of 
fatal  results. 

Diagnosis  of  Chronic  Obstruction. — The  symptoms  of  chronic  ob- 
struction are  the  same  as  those  of  the  acute  form,  only  milder  in 
degree.  The  history  of  the  case  will  reveal  some  chronic  intestinal 
disease,  such  as  carcinoma,  ulceration,  or  morbid  growth.  Repeated 
occurrences  of  obstructive  .symptoms  will  be  followed  by  periods  of  relief, 
but  the  tendency  is  for  these  attacks  to  return  with  increased  frequency, 
and  finally  wind  up  with  complete  occlusion,  when  the  symptoms  will 
be  intensified  into  the  typical  character  of  complete  obstruction.  Pain 
is  not  so  marked  a  symptom  as  in  the  acute  variety,  in  many  cases 
coming  on  after  eating.     It  occurs  in  paroxysms   and  has  periods  of 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE   SYSTEM.       255 

complete  intermission.  Vomiting  appears  later  or  not  at  all,  and  is 
rarely  feculent.  Constipation  is  usually  present,  but  may  alternate 
with  attacks  of  diarrhea.  Instead  of  the  abdominal  distention  which 
is  so  marked  a  character  of  acute  obstruction,  we  may  have  only 
attacks  of  flatulence,  which,  however  distressing,  may  not  cause 
dyspnea  except  when   death  is  approaching. 

In  the  large  intestine  the  most  common  form  of  obstruction  is  car- 
cinoma of  the  rectum.  Its  diagnosis  is  not  difficult,  but  obstruction 
higher  up  may  be  obscure.  The  symptoms  of  obstruction  in  the  large 
intestine  as  distinguished  from  the  smaller  bowel  may  be  summed  up  as 
follows :  Vomiting  is  less  frequent,  distention  is  more  marked,  and 
there  is  tenesmus  with  discharge  of  blood  or  pus. 

Diagnosis  of  Fecal  Accumulations. — These  occur  in  the  large  intes- 
tine only,  and  for  obvious  reasons  the  cecum  and  the  sigmoid  flexure 
of  the  colon  are  the  two  points  at  which  obstruction  most  frequently 
takes  place.  In  a  case  reported  by  Jessett  the  hypochondriac  and  right 
iliac  regions  were  filled  by  a  tumor  which  extended  to  the  umbilicus, 
and,  having  the  shape  of  the  liver,  was  diagnosticated  as  carcinoma  of 
that  organ.  The  patients  are  for  the  most  part  women  who  have 
passed  the  active  period  of  life,  and  lunatics.  The  history  of  a  case  of 
this  kind  is  one  of  obstinate  constipation,  going  on  from  bad  to  worse. 
In  some  cases  there  is  diarrhea,  which,  paradoxical  as  it  may  appear,  is 
often  present  when  the  bowel  is  obstructed  by  a  mass  of  feces.  The 
tumor  is  not  only  plainly  to  be  felt,  but  may  be  visible.  Its  consistency 
is  frequently  an  indication  of  its  character.  There  is  no  other  tumor  in 
which  a  permanent  indentation  remains  after  pressure  by  the  fingers. 

Treatment. — Purgatives  are  not  only  useless,  but  dangerous.  If  the 
accumulation  is  low  down  in  the  sigmoid  flexure  and  filling  the  rectum, 
the  masses  can  be  broken  up  and  removed  with  a  scoop  or  the  handle 
of  a  tablespoon.  Repeated  enemata  of  sweet  oil,  followed  by  copious 
injections  of  soap  and  water,  give  good  results.  Strychnin  has  a  good 
effect  in  restoring  the  muscular  contractility  of  the  bowel  and  increasing 
peristalsis.  To  these  measures  may  be  added  massage  and  the  use  of 
the  faradic  current.  It  must  be  remembered  that  a  person  who  has 
once  suffered  from  fecal  accumulation  is  liable  to  a  recurrence,  hence 
every  care  should  be  taken  to  maintain  the  bowels  in  a  healthy  state. 

V.  HERNIA. 

The  protrusion  of  a  viscus  from  its  natural  cavity  through  a  dis- 
tended normal  or  an  artificial  opening  is  called  a  hernia.  It  includes 
not  only  abdominal  protrusions,  but  also  those  occurring  in  the  thorax, 
the  cranial  cavity,  etc.  In  common  parlance  the  term  is  applied  to  the 
escape  of  abdominal  contents  through  the  parietes,  either  at  one  of  the 
natural  openings,  as  the  inguinal  or  femoral  canals,  or  at  weak  points, 
such  as  the  umbilicus  or  the  thin  cicatrix  left  after  abdominal  section. 
Clinically,  we  meet  with  hernia  under  various  circumstances.  One  case 
may  be  strangulated  and  threatening  to  prove  fatal  in  a  few  hours 
unless  relieved  ;  another  demands  attention,  owing  to  the  inconvenience 
and  pain  produced  by  an  ever-increasing  tumor  which  cannot  be  kept 
within  the  abdomen.    *'  The  life  of  a  person  afflicted  with  a  hernia,"  says 


256  SURGICAL   DIAGNOSIS  AiXD    TREATMENT. 

Championnicre,  "  is  generally  a  sad  and  painful  one.  He  has  to  carry 
all  his  lifetime  a  truss  more  or  less  fitting,  more  or  less  adapted  to  his 
needs.  He  is  incapable  of  vigorous  exertion,  and  the  intestines,  pass- 
ing in  and  out  of  the  hernial  sac,  give  rise  to  colic  more  or  less  severe. 
Sometimes  the  hernia  is  never  reduced  completely,  and  the  patient  is 
always  threatened  with  strangulation. 

"  Besides  these  inherent  defects  accompanying  a  hernia,  it  is  demon- 
strated that  the  sufferers  are  subject  to  a  peculiar  lack  of  vitality, 
especially  in  those  afflicted  with  hernial  of  large  size  or  of  long  standing. 
The  majority  of  these  cases  are  troubled  with  diabetes  or  albuminuria. 
Hernia  thus  leads  to  an  inevitable  cachexia  of  which  albuminuria  and 
diabetes  are  very  grave  results." 

The  diagnosis  of  hernia  seldom  presents  great  difficulty,  but  the 
most  serious  consequences  frequently  arise  from  failure  to  recognize 
this  condition.  A  young  physician  is  called  to  attend  a  man  who  is 
suffering  intense  abdominal  pain.  He  makes  a  hasty  examination, 
employs  a  hypodermic  of  morphia  and  hot  fomentations,  with  assurance 
that  the  disease  is  only  colic  and  that  the  patient  will  be  all  right  next 
day.  For  three  days  the  condition  grows  steadily  worse  ;  vomiting  sets 
in  and  becomes  feculent.  Another  physician  is  called,  who,  recognizing 
a  strangulated  hernia,  sends  the  man  to  a  hospital.  An  operation  is 
performed  at  midnight,  but  the  patient  dies  upon  the  operating-table. 
There  are  few  surgeons  of  large  hospital  experience  who  have  not 
seen  cases  with  this  unfortunate  history.  In  severe  abdominal  pain  or 
vomiting  an  examination  for  strangulated  hernia  shoidd  never  be  neglected. 

The  causes  of  hernia  are  predisposing  and  exciting.  Certain  parts 
of  the  abdominal  wall  are  naturally  weaker  than  others,  as  the  inguinal 
ring,  the  femoral  ring,  and  the  umbilicus.  Certain  abnormalities  tend 
to  hernia,  as  late  descent  of  the  testes,  patulousness  of  the  inguinal 
canal,  patency  of  the  tunica  vaginalis,  lengthening  of  the  mesentery, 
and  separation  of  the  recti  muscles.  Among  acquired  defects  may  be 
mentioned  abdominal  operations,  in  which  the  tissues  have  not  been 
brought  into  perfect  apposition  or  where  undue  tension  or  suppuration 
has  prevented  the  formation  of  a  firm  cicatrix.  Repeated  pregnancies 
and  distention  of  the  abdomen  by  ascites  and  sudden  emaciation  are 
also  predisposing  causes.  The  immediate  or  exciting  causes  are  chiefly 
the  action  of  the  abdominal  muscles.  Consequently,  those  persons  who 
engage  in  laborious  occupations  and  frequently  make  strong  muscular 
efforts  are  most  liable  to  hernia,  and  especially  if  there  is  a  predisposi- 
tion. Violent  efforts  in  coughing,  straining  at  stool,  and  in  urination 
are  also  exciting  causes. 

A  long  mesentery  favors  the  descent  of  a  hernia  in  adult  life.  The 
congenital  variety  occurs  more  frequently  on  the  right  side  than  on  the 
left,  owing  to  the  fact  that  the  root  of  the  mesentery  lies  lower  on  that 
side.  All  perversions  of  function  or  diseases  of  the  intestinal  tract 
which  cause  relaxation  of  the  mesentery  favor  descent  of  a  hernia. 

Prolapse  of  the  mesentery  has  been  considered  very  important.  It 
occurs  during  late  adult  life,  and  is  accompanied  by  a  characteristic  and 
readily  recognized  bulging  of  the  lower  part  of  the  abdomen.  The 
epigastric  region  is  depressed,  while  below  there  is  a  bulging  both  at 
the  sides  and  in  the  median  line,  where  the  muscles  are  the  weakest, 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE   SYSTEM.        257 

and  a  radical  cure  which  is  attempted  for  the  purpose  of  rendering  the 
abdominal  parietes  more  firm  and  resistant  must  of  necessity  fail,  for 
the  reason  that  the  root  of  the  mesentery  has  been  weakened  from 
some  cause  and  has  slipped  down. 

Certain  hereditary  conditions  no  doubt  predispose  to  hernia.  The 
inguinal  forms  occur  more  frequently  in  men  than  in  women,  while  the 
femoral  and  umbilical  are  more  common  in  the  latter. 

Varieties. — Hernia  is  classified  according  to  the  position  which  it 
occupies — viz.  inguinal,  femoral  or  crural,  umbilical,  ventral,  diaphrag- 
matic, etc.  Of  these  the  inguinal  is  by  far  the  most  common,  occur- 
ring in  80  per  cent,  of  all  cases.  Classified  according  to  the  manner  in 
which  the  sac  is  formed,  herniae  are  divided  into  two  classes — congenital 
and  acquired. 

The  contents  of  a  hernial  tumor  are  made  up  of — (i)  a  sac,  which 
is  always  the  peritoneum,  except  in  the  very  rare  cases  where  a  portion 
of  bowel  uncovered  by  peritoneum  escapes  ;  (2)  a  loop  of  intestine, 
generally  the  ileum ;  (3)  omentum.  The  character  of  the  contents  is 
expressed  by  using  the  Greek  name  of  the  viscus  and  the  termination 
cele  {rqXrj,  a  tumor) ;  thus  we  have  enterocele  when  the  tumor  contains 
intestine ;  epiplocele  when  the  oment?im  occupies  the  sac ;  entero- 
epipiocele  when  the  sac  contains  both  intestine  and  omentum.  In 
addition  to  the  foregoing,  it  is  common  to  find  in  any  hernial  sac  a 
small  quantity  of  serous  fluid. 

From  a  clinical  standpoint  every  hernia  falls  into  one  of  three 
classes :  Reducible,  when  the  contents  of  the  sac  can  be  returned  to 
the  abdominal  cavity  by  simple  manipulation ;  irreducible,  when, 
owing  to  the  formation  of  firm  adhesions,  reduction  cannot  be  accom- 
plished ;  and  strangulated,  when  constriction  at  the  neck  of  the  hernia 
not  only  prevents  the  passage  of  the  intestinal  contents  at  that  point, 
but  obstructs  the  circulation  in  the  bowel-wall  and  speedily  leads  to 
gangrene. 

Symptoms. — Four-fifths  of  all  cases  of  hernia  occur  in  males.  The 
patient,  as  a  rule,  only  consults  a  surgeon  after  he  or  his  friends  have 
recognized  the  existence  of  a  tumor  in  the  groin,  scrotum,  or  elsewhere. 
There  are  many  cases  in  which  the  patient  is  unaware  of  the  nature  of 
his  infirmity,  and  yet  there  are  certain  warnings  which  should  arouse 
the  surgeon's  suspicion.     These  are — 

1.  A  feeling  of  weakness  at  a  certain  point,  relieved  by  the  support 
of  the  hand  or  on  assuming  the  recumbent  posture. 

2.  Colicky  pain  and  griping,  supposed  to  be  due  to  dragging  on  the 
mesentery.     This  is  more  noticeable  on  exertion  and  after  eating. 

3.  During  sudden  efforts,  in  which  the  abdominal  muscles  are 
brought  into  violent  contraction,  the  patient  feels  that  something 
has  given  way. 

4.  Mo.st  important  of  all  is  the  agonizing  pain  which  is  characteristic 
of  strangulation.  It  is  generally  felt  at  the  umbilicus,  and  patients 
describe  it  as  twisting  in  character. 

The  Tumor. — Drawn  to  make  a  local  examination  by  one  or  more  of 
these  warnings,  a  tumor  will  be  found,  the  character  of  which  depends 
upon  its  contents.  If  composed  of  intestine,  the  surface  is  smooth  and 
elastic,  and  if  large  enough  for  percussion  it  is  resonant.     Place  your 

17 


258  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

fingers  upon  it  and  ask  the  patient  to  cough— a  distinct  impulse  is  felt. 
This  impulse  on  coughing  may  be  regarded  as  the  pathognomonic  sign 
of  hernia,  and  an  examination  without  looking  for  it  is  no  examination 
at  all.  The  patient  should  be  examined  while  he  is  standing  up,  as  well 
as  while  he  is  lying  down.  If  he  stands  upon  a  chair,  it  is  still  better, 
as  the  hernia  can  be  examined  at  the  level  of  the  surgeon's  hand.  This 
is  a  very  favorable  position  for  the  determination  of  multiple  herniae 
(Championniere).  When  omentum  constitutes  the  bulk  of  the  tumor 
the  impulse  is  not  so  expansile;  the  tumor  is  hard,  doughy,  and 
uneven. 

An  enterocele  slips  back  quickly  when  reduced,  and  there  is  a 
peculiar  gurgle  which  is  a  welcome  sound  to  the  surgeon's  ear. 
Epiplocele,  on  the  other  hand,  goes  back  slowly,  and,  containing  no 
gas,  there  is  of  course  no  gurgle. 

Having  settled  the  point  that  the  tumor  is  a  hernia,  the  next  ques- 
tion is  whether  it  is  above  or  below  Poupart's  ligament.  If  above,  it  is 
an  inguinal  hernia ;  if  below,  it  is  a  femoral  hernia.  The  spine  of  the 
pubis  is  an  important  landmark.  An  inguinal  hernia  always  protrudes 
at  the  external  ring  just  at  the  spine,  and  lies  above  Poupart's  ligament. 
A  femoral  hernia  is  always  below  the  spine. 

Inguinal  hernia  occurs  as  a  tumor  near  the  center  of  Poupart's 
ligament.  There  are  two  varieties — viz.  oblique  or  external,  direct  or 
internal.  In  the  indirect  hernia  the  bowel  escapes  from  the  abdominal 
cavity  at  the  internal  abdominal  ring,  pushing  the  peritoneum  before  it, 
and,  following  the  inguinal  canal,  emerges  at  the  external  ring.  Along 
this  same  route  the  testicle,  on  the  way  to  the  scrotum,  has  been  the 
pioneer,  and  the  intestine  may  follow  it  the  entire  distance.  The  epi- 
gastric vessels  lie  to  the  inside  of  the  neck  of  the  tumor.  In  the  direct 
form  the  bowel  does  not  enter  the  internal  ring  or  traverse  the  inguinal 
canal,  but,  pushing  the  fascia  before  it,  escapes  directly  through  the 
external  ring. 

In  examining  the  tumor  these  two  forms  can  generally  be  differ- 
entiated. The  indirect  form  is  by  far  the  more  common ;  the  tumor  is 
oval  in  shape  or,  when  it  has  descended  to  the  scrotum,  it  is  pyriform. 
The  history  of  the  case  will  show  that  the  tumor  began  to  appear  at 
the  middle  of  Poupart's  ligament  and  gradually  extended  toward  the 
pubes.  The  pulsation  in  the  epigastric  vessels  is  usually  obscured. 
The  size  of  the  tumor  is  sometimes  immense,  in  some  cases  filling  the 
scrotum  and  causing  it  to  drag  downward  until  it  comes  almost  to  the 
knee.  The  indirect  hernia  usually  contains  intestine.  It  is  reduced  by 
pressure  outward  and  backw^ard. 

Direct  inguinal  hernia  is  rare.  The  tumor  is  small  and  globular, 
usually  making  its  appearance  a  little  to  the  inside  of  the  middle  of 
Poupart's  ligament.  It  generally  contains  omentum,  and  the  epigastric 
vessels  lie  to  the  outer  side.  It  is  reduced  by  pressure  directly  back- 
ward. The  finger-tips  can  be  pushed  through  the  canal  directly  into 
the  abdominal  cavity.  On  the  inner  side  of  the  opening  can  be  felt 
the  conjoined  tendon  and  the  posterior  upper  surface  of  the  pubis ; 
on  the  outer  side  is  the  epigastric  artery.  When  a  hernia  is  large  and 
of  long  standing,  the  differential  diagnosis  may  be  impossible,  for  the  in- 
ternal may  be  dragged  downward  until  it  is  opposite  to  the  external  ring. 


INJURIES  AND  DISEASES  OF   THE   DIGESTIVE   SYSTEM.       259 

Femoral  hernia  is  a  female  hernia ;  that  is  to  say,  it  is  much  more 
frequently  met  with  in  women  than  in  men.  Its  position  is  in  the 
crural  canal,  which  has  the  following  anatomical  boundaries  :  In  front, 
Poupart's  ligament,  the  deep  crural  arch,  and  the  falciform  edge  of  the 
fascia  lata  ;  on  the  outer  side,  the  femoral  vein  ;  on  the  inner  side,  Gim- 
bernat's  ligament ;  and  behind,  the  bone.  The  anatomical  landmark 
for  this  hernia  is  the  spine  of  the  pubes.  A  femoral  hernia  is  always 
below  it  and  to  the  outer  side. 

In  hernia  of  long  standing  and  of  considerable  size  it  may  be  diffi- 
cult to  say  whether  the  tumor  is  above  or  below  Poupart's  ligament, 
for  as  it  enlarges  it  turns  upward  and  toward  the  abdomen,  giving  the 
appearance  of  an  inguinal  hernia.  What  adds  to  the  difficulty  is  the 
existence  in  some  women  of  a  fold  of  the  groin  which  extends  across 
the  thigh  lower  down  than  Poupart's  ligament,  and  may  be  mistaken 
for  it.  When  a  femoral  hernia  remains  in  the  crural  arch  it  is  said  to  be 
incomplete ;  when  it  protrudes  at  the  saphenous  opening  it  is  called 
complete. 

Diagnosis  between  hernia  and  other  swellings  of  the  inguinal  or 
femoral  region  : 

Bubo  is  generally  associated  with  chancroids,  gonorrhea,  and 
syphilis,  and  there  are  redness  of  the  skin  and  tenderness.  If  the 
swelling  and  subcutaneous  infiltration  are  not  too  great,  the  outline  of 
the  inflamed  gland  can  be  felt.  Chronic  inflammation  of  a  gland  in  the 
groin  seldom  leads  to  confusion,  as  the  glands  are  distinct  and  movable. 
Glands  enlarged  by  malignant  disease  are  hard  and  frequently  occur  in 
chains. 

Undescended  testicle  has  the  characteristic  pain  on  pressure  pecu- 
liar to  these  organs,  and,  besides,  there  is  absence  of  the  testis  in  the 
scrotum. 

Varicocele  is  a  swelling  resembling  a  bunch  of  worms,  commencing 
in  the  lower  portion  of  the  cord  and  increasing  upward.  There  is  no 
impulse  on  coughing.  The  swelling  may  disappear  when  the  patient 
lies  down,  as  is  sometimes  the  case  in  hernia.  If  the  part  be  supported 
and  the  patient  stand  up,  the  swelling  will  return  in  the  case  of  varico- 
cele, but  not  so  if  the  case  be  one  of  hernia. 

Hydrocele  is  translucent,  and  the  swelling  begins  at  the  lowest  part 
of  the  scrotum,  while  in  hernia  this  is  the  ultima  thule.  Hydrocele  of 
the  cord  is  never  very  large,  and  has  but  a  slight  impulse  on  coughing. 
The  swelling  moves  with  the  cord. 

Abscess  in  the  neighborhood  of  Poupart's  ligament  may  assume 
the  shape  of  a  hernial  tumor,  but  there  are  the  characteristics  symp- 
toms of  suppuration,  pain,  high  temperature,  etc.  Psoas  abscess  has  a 
history  of  spinal  or  pelvic  disease  ;  the  tumor,  if  superficial,  fluctuates 
and  gradually  disappears  under  pressure. 

Irreducible  Hernia. — When,  without  impairment  of  the  circula- 
tion or  the  passage  of  feces,  a  hernia  cannot  be  returned  into  the 
abdomen,  it  is  said  to  be  irreducible.  This  may  be  brought  about  by 
a  variety  of  causes :  the  hernia  may  be  composed  of  omentum,  which 
takes  a  mushroom  shape,  a  small  neck  and  an  expanded  body ;  a  large 
quantity  of  fluid  in  the  sac  may  interfere  with  direct  manipulation  of 
the  bowel ;  or  the  great  size  of  the  tumor  may  in  itself  be  an  obstacle 


260  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

to  reduction.  The  most  frequent  cause,  however,  is  the  existence  of 
adhesions,  either  between  the  sac  and  its  contents  or  between  the  con- 
tents themselves.  Irreducible  hernial  are  the  cause  of  great  discomfort. 
More  and  more  of  the  intestine  slips  down  into  the  sac  until  the  tumor 
reaches  an  enormous  size.  Continual  dragging  pain,  dyspepsia,  colic, 
and  the  ever-present  danger  of  strangulation  make  the  patient's  lot 
anything  but  pleasant. 

Incarcerated  or  Obstructed  Hernia. — When,  without  any  inter- 
ference with  circulation,  the  loop  of  bowel  contained  in  a  hernia 
becomes  impacted  with  feces  and  gases,  the  hernia  is  said  to  be  incar- 
cerated or  obstructed.  This  only  happens  when  the  colon  goes  to  form 
the  hernia,  as  the  contents  of  the  small  intestine  are  always  liquid. 
This  condition  is  most  frequently  met  with  in  umbilical  hernia,  especially 
in  that  form  which  afflicts  women  who  have  borne  many  children.  It  is 
easy  of  recognition.  The  tumor  is  hard  and  uneven,  and  in  some  cases 
tympanitic.  It  hangs  down  from  the  umbilicus,  and  usually  attains  con- 
siderable size,  attended  with  colic,  nausea,  and  total  constipation  after 
the  lower  bowel  has  been  emptied. 

Strangulated  Hernia. — A  strangulated  hernia  is  one  in  which 
constriction  at  the  neck  is  so  complete  as  to  arrest  the  circulation, 
paralyze  the  nerves,  and  stop  the  flow  of  contents  through  the  bowel. 
Such  a  condition  is  naturally  attended  with  the  utmost  danger,  and  its 
progress  is  rapid — from  strangulation  to  gangrene  is  a  short  step.  It 
is  not  essential  that  the  hernia  should  contain  intestine,  for  when  the 
sac  contains  omentum,  or,  in  fact,  any  other  structure,  the  course  and 
symptoms  are  the  same.  When  the  bowel  is  involved  it  may  be  con- 
stricted at  one  side  or  in  its  whole  circumference.  In  either  case  per- 
foration is  the  usual  consequence,  the  contents  of  the  bowel  escaping 
in  some  instances  into  the  peritoneal  cavity,  setting  up  general  peri- 
tonitis. In  others  they  are  poured  out  into  the  sac  and  followed  by 
suppuration. 

Svviptoins. — If  once  the  existence  of  hernia  be  recognized  and  the 
symptoms  of  strangulation  superadded,  error  in  diagnosis  is  impossible, 
The  danger  of  making  a  false  diagnosis  lies  in  the  fact  that  the  con- 
dition may  be  regarded  as  due  to  gastritis  when  vomiting  is  an  early 
and  prominent  symptom,  or  to  peritonitis  when  pain  and  abdominal 
tenderness  are  most  marked.  Two  classes  of  symptoms  must  be 
recognized — one  due  to  obstniction  of  the  bowel,  the  other  to  strangula- 
tion. In  every  case  of  severe  abdominal  pain  or  persistent  vomiting  the 
question  of  hernia  should  be  considered,  and  every  probable  site  of 
hernia  should  be  carefully  examined. 

Pain  is  usually  an  early  and  prominent  symptom.  It  is  generally 
referred  to  one  spot,  the  seat  of  the  hernia,  but  frequently,  and  espe- 
cially at  a  later  stage,  it  is  felt  at  the  umbilicus,  and  described  as  if  the 
intestines  were  being  violently  twisted  at  that  point.  Tenderness  is 
most  marked  at  the  seat  of  hernia,  but  is  commonly  a  marked  symp- 
tom over  the  whole  abdomen.  W^hen  gangrene  has  become  complete 
pain  ceases,  and  its  sudden  cessation  may  be  regarded  as  a  harbinger 
of  death.  Too  much  reliance  should  not  be  placed  upon  pain  as  a 
symptom.  In  some  cases  it  is  almost  absent,  and  in  others  its  onset 
is  delayed. 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE   SYSTEM.       26 1 

Vomiting  may  come  on  at  the  very  commencement  of  strangulation, 
or  it  may  appear  at  a  much  later  period.  The  higher  the  strangulation 
in  the  bowel,  the  earlier,  as  a  rule,  will  vomiting  set  in.  At  first  the 
food  newly  received  into  the  stomach  is  ejected  undigested  and  unal- 
tered. After  a  time  the  gastric  secretions,  still  later  the  chyle  and  bile, 
are  ejected,  and  lastly  the  vomit  assumes  all  the  characteristics  of  fecal 
matter. 

Obstruction  is  manifested  by  constipation,  which  is  persistent  and 
complete.  After  the  bowel  below  the  strangulation  has  been  emptied 
nothing  more,  not  even  flatus,  comes  away.  The  abdomen  gradually 
becomes  distended  and  tympanitic,  but  the  area  of  liver-dulness  remains 
intact,  thus  showing  that  the  gas  is  in  the  intestine  and  not  in  the  peri- 
toneal cavity.  The  part  of  the  intestinal  canal  implicated  may  be 
approximately  determined.  If,  after  the  onset  of  the  symptoms,  a 
considerable  evacuation  takes  place  from  the  bowels,  it  may  be  con- 
cluded that  the  obstruction  is  in  the  small  intestine.  Distention  also 
comes  on  slowly  if  the  lower  intestine  be  the  strangulated  part. 

The  tcvipcraturc  is  seldom  above  normal,  and  in  the  late  stages  it 
becomes  subnormal. 

The  pulse  is  generally  rapid,  and  becomes  feeble  and  intermittent 
toward  the  close. 

Examination  of  the  hernial  tumor  will  reveal  tenderness  at  the  seat 
of  strangulation.  There  is  absence  of  impulse  on  coughing.  The 
later  history  of  a  case  of  strangulation  is  the  history  of  gangrene.  If 
we  were  restricted  to  the  use  of  two  words  in  describing  the  course  of 
a  strangulated  hernia,  we  would  not  be  far  astray  if  we  used  peritonitis 
and  gangrene.  The  first  acute  onset  with  its  violent  pain  and  other 
signs  of  peritonitis  passes  into  a  stage  in  which  the  constitutional 
symptoms  play  a  more  prominent  part.  More  and  more  offensive 
becomes  the  vomited  matter,  and  it  comes  in  great  gushes  without 
any  effort ;  the  pulse  becomes  feeble  and  intermittent ;  hiccough  is  con- 
stant and  distressing ;  the  abdomen  becomes  more  and  more  distended ; 
the  face  is  haggard  ;  the  mind  wanders  ;  the  surface  of  the  body  becomes 
cold  and  clammy ;  and  death  by  exhaustion  ends  the  fearful  scene. 

In  rare  cases  nature  brings  relief  and  prevents  a  fatal  termination. 
The  tumor  is  swollen  and  edematous,  and  even  tympanitic  from  the 
putrefying  gases  ;  the  skin  ulcerates  and  the  contents  escape,  leaving 
the  patient  his  life,  but  with  it  the  misery  of  an  artificial  anus. 

When  the  hernia  contains  omentum  only,  or  when  only  a  part  of 
the  circumference  of  the  bowel  is  strangulated  (Littre's  hernia),  the 
symptoms  are  the  same,  only  in  a  less  marked  degree. 

Differential  diagnosis  of  strangulated  hernia  must  rest  between 
hernia  and — 

1.  Acute  peritonitis.  The  existence  of  a  hernia  previous  to  the 
onset  of  symptoms  and  the  presence  of  a  tumor  must  be  mainly 
relied  upon  to  exclude  peritonitis. 

2.  Inflamed  or  obstructed  irreducible  hernia.  The  pain,  constipa- 
tion, and  collapse  are  never  so  marked  as  in  strangulation.  The 
vomiting  is  not  fecal. 

Treatment  of  Strangulated  Hernia. — A  condition  so  grave  and 
violent  in   its  progress  demands  the  most  prompt  and  decisive  treat- 


262  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

mcnt.  Strangulation  must  be  relieved  or  death  will  most  certainly 
result.  Two  measures  are  relied  upon — taxis  and  operation.  In 
employing  taxis  or  manipulation  the  first  point  demanding  attention  is 
to  secure  complete  relaxation  of  the  parts.  The  head  should  be 
lowered  and  the  pelvis  raised.  If  the  hernia  be  inguinal,  flex  and 
adduct  the  thigh  ;  if  femoral,  flex  and  rotate  inward.  Steady  the  neck 
of  the  sac  with  the  left  hand  while  the  right  gently  manipulates  the 
tumor  with  the  view  of  emptying  it  of  part  of  its  contents.  If  intestine 
slips  back,  a  welcome  gurgle  announces  the  fact ;  omentum  goes  back 
more  slowly,  but  with  an  equal  sense  of  relief  Should  gentle  efforts  at 
reduction  fail,  more  complete  relaxation  of  the  parts  must  be  secured  by 
putting  the  patient  under  chloroform.  But  before  doing  so  every  prep- 
aration should  be  made  for  an  operation  in  the  event  of  taxis  proving 
a  failure.  This  is  required  for  two  reasons — first,  because  the  patient 
should  be  subjected  to  anesthesia  only  once ;  and  second,  because  the 
case,  if  unrelieved  by  taxis,  will  not  admit  of  a  moment's  delay. 

The  operation  for  strangulated  hernia  or  herniotomy  consists  in  cut- 
ting down  upon  the  constriction,  dividing  it,  and  returning  the  bowel  to 
the  abdominal  cavity,  or  otherwise  dealing  with  it  as  circumstances 
demand.  The  pubes,  scrotum,  and  neighboring  parts  having  been 
shaved  and  thoroughly  disinfected,  an  incision  is  made  in  the  long  axis 
of  the  tumor,  the  center  of  the  incision  corresponding  with  the  position 
of  the  neck  of  the  sac.  The  next  point  is  to  find  the  sac,  which,  to  an 
inexperienced  operator,  may  be  a  little  difficult.  It  is  recognized  by 
the  fat  which  usually  covers  it ;  grasped  by  the  finger  and  thumb,  its 
surfaces  can  be  made  to  slip  over  each  other.  Carefully  dissecting 
down  through  the  tissues,  we  know  that  we  have  entered  the  sac  by 
the  escape  of  a  yellow  or  dark-brown  fluid.  Through  the  puncture  in 
the  sac  a  groov^ed  director  is  passed,  and  an  opening  made  sufficient  to 
admit  the  finger,  upon  which  the  sac  is  divided  to  the  full  extent  of 
the  tumor.  The  finger  is  now  passed  up  to  the  constriction,  palmar 
surface  upward,  and  the  nail  slipped  into  the  opening.  A  long  probe- 
pointed  bistoury  is  passed  up,  the  flat  surface  of  the  instrument  against 
the  palmar  surface  of  the  finger,  until  it  slips  between  the  sharp  edge 
of  the  constriction  and  the  nail.  The  edge  is  now  turned  upward  and 
the  ring  sufficiently  divided  to  relieve  the  strangulation. 

The  contents  of  the  hernia  should  now  be  carefully  examined,  and 
especially  the  bowel.  Warm  sterilized  gauze  is  applied  to  the  wound, 
and  allowed  to  remain  for  several  minutes  in  the  hope  that  circulation 
may  be  re-established  in  the  strangulated  tissues.  A  strangulated 
intestine  varies  in  color  from  a  pinkish  gray  to  black  ;  if  in  the  course 
of  five  to  fifteen  minutes  it  changes  to  a  healthy  red,  circulation  is 
restored  and  the  bowel  can  be  returned  to  the  abdomen.  The  sac  is 
then  treated  in  the  same  manner  as  in  the  radical  operation  for  hernia,, 
and  the  operation  completed  as  described  under  the  radical  operation. 
When  omentum  is  contained  in  the  sac,  it  should  be  separated  if 
adherent,  tied  in  sections,  and  cut  off 

Should  the  intestine  prove  to  be  gangrenous,  it  may  be  dealt  with  by 
one  of  three  methods:  i.  The  gangrenous  portion  is  exsected  ;  the 
healthy  divided  ends  are  brought  together  by  end-to-end  anastomosis 
(enterectomy).     2.  An  artificial  anus  is  formed  by  suturing  the  bowel 


INJURIES  AND   DISEASES   OF   THE   DIGESTIVE   SYSTEM.        263 

to  the  edge  of  the  wound  and  opening  into  its  lumen.  3.  The  bowel 
is  returned  to  the  abdominal  cavity,  stitching  it  to  the  abdominal  wall 
inside  the  ring,  and  placing  a  drainage-tube  in  contact  with  it.  This  is 
only  applicable  when  the  portion  of  gangrenous  bowel  is  small. 

The  Radical  Cure  of  Hernia.' — In  the  case  of  strangulated  hernia 
"  the  radical  cure  "  is  a  term  applied  to  a  method  of  treating  the  sac 
and  closing  the  canal  which  prevents  recurrence  of  the  hernia.  Its 
usefulness  is,  however,  by  no  means  limited  to  strangulated  hernia,  for 
it  is  almost  universally  adapted  to  those  unfortunates  who  are  doomed 
to  carry  a  truss  through  life,  who  are  constantly  threatened  with  the 
dangers  which  are  for  ever  hanging  over  the  heads  of  the  ruptured,  or 
who  are  shut  out  from  many  of  the  active  walks  of  life  by  these 
inflictions. 

Long  is  the  history  which  deals  with  the  various  attempts  at  the 
radical  treatment  of  hernia.  Some  were  subcutaneous,  as  Wood's 
and  Spanton's,  but  the  advance  of  aseptic  surgery  has  proven  that  not 
only  greater  accuracy,  but  equal  safety,  is  gained  by  operations  which 
lay  the  parts  open  to  view  and  deal  with  the  separate  structures  as 
their  condition  demands. 

The  operation  is  imperative  in — (i)  strangulated  hernia;  (2)  in 
herniae  whose  volume  is  gradually  increasing. 

The  operation  is  indicated  in  (i)  irreducible  herniae ;  (2)  congenital 
herniae  with  ectopic  testicles  ;  (3)  painful  herniae  ;  (4)  herniae  in  subjects 
afflicted  with  diseases  that  form  dangerous  complications,  as  spasmodic 
asthma,  chronic  cough,  etc. ;  (5)  social  necessities  may  demand  the  ope- 
ration, as  in  those  who  have  to  perform  manual  labor,  those  who  wish 
to  enter  the  military  service,  etc. 

The  operation  is  contraindicated  in — (i)  old  men  and  very  young 
children  (under  six  years  of  age) ;  (2)  persons  who  have  albuminuria, 
diabetes,  or  tuberculosis  :  those  afflicted  with  emphysema  are  the  most 
dangerous  of  all ;  (3)  those  predisposed  to  hernia. 

If  we  bear  in  mind  the  conditions  essential  to  the  existence  of  a 
hernia,  the  indications  of  treatment  will  be  better  understood. 

1.  In  every  hernia  there  is  an  enlarged  foramen  or  canal  in  the 
abdominal  wall  (Fig.   118). 

2.  Protruding  through  this  opening  is  a  serous  sac  which  forms  an 
inclined  plane,  smooth  and  slippery,  on  which  the  viscera  glide. 

3.  The  viscera  which  form  the  hernia  are  generally  the  intestines  and 
the  omentum.  Everything  tends  to  place  the  intestines  upon  this  slip- 
pery surface.  Ordinarily  the  intestine  is  loose  on  this  inclined  plane, 
but  sometimes  it  forms  adhesions  with  the  omentum,  which  goes  down 
with  it. 

In  view  of  the  principles  just  laid  down  we  have  three  indications 
which  must  be  fulfilled  as  much  as  possible : 

I.  The  serous  membrane  must  be  modified  or  destroyed,  for  the 
destruction  of  the  slippery  surface  will  remove  the  tendency  of  the 
intestines  to  slide  over  it. 

The  opening  of  the  sac,  and  then  its  removal  at  the  highest  possible 
point,  will  destroy  the  slippery  inclined  plane.     In  order  that  this  de- 

1  For  much  that  follows  I  am  indebted  to  the  excellent  work  of  Champion niere,  Ctire 
radicale  des  Hernies,  Rouff,   Paris. 


264 


SURGICAL    DIAGNOSIS  AND    TREATMENT. 


struction  be  complete,  the  serous  membrane  away  above  the  neck  of  the 
sac  must  be  removed  with  it  and  the  oi)ening  closed  by  a  strong  liga- 
ture, so  that  no  cul-de-sac  or  infundibulum  be  apparent,  and  that  in  the 


Fig.  118. — Schema  of  the  constituents  of  a 
hernia;  sac  and  slippery  surface  traversing  the 
wall  (Championniere). 


Fig.  119. — Schema  of  the  radical  cure, 
restoration  of  the  wall,  closure  of  the  serous 
membrane  :  A,  closure  of  the  wall ;  B,  closure 
of  the  skin  (Championniere). 


region  which  the  hernia  occupied  we  find  only  a  smooth  plane  contin- 
uous with  the  rest  of  the  deep  surface  of  the  abdominal  wall  (Fig.  119). 
2.  We  must  build  up  at  the  opening  in  the  abdominal  wall  a  most 
resisting  cicatrix  as  a  powerful  barrier  to  prevent  the  forcing  out  of  the 


Fig.  120. — Serous  sac  of  a  hernia  with 
the  points  {A  and  B)  at  which  the  de- 
struction of  the  serous  sac  must  take 
place  (Championniere). 


Fig.  121. — Sac  drawn  down  by  traction 
and  dissection  ;  the  points  A  and  B  have 
descended  to  A'  and  B'  (Championniere). 


viscera  which  have  a  tendency  to  come  down.  This  point  is  gained 
by  the  close  approximation  of  a  large  operation-wound.  The  extensive 
dissection  of  the  serous   membrane  is  an  important  preparatory  step, 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE   SYSTEM.       265 

and  it  may  be  said  that  the  larger  the  incision  the  more  powerful  will 
be  the  cicatrix. 

3.  If  intervention  with  the  contents  of  the  sac  be  possible,  we  must 
destroy  the  parts  not  essential  to  the  functions  of  the  abdomen — e.  g. 
the  omentum.  The  omental  mass  contained  in  the  sac  should  not 
only  be  removed,  but  all  that  can  be  drawn  down  by  strong  effort. 
This  is  all  cut  off,  thus  creating  in  the  abdomen  a  corresponding 
vacuum  (Figs.  120  and  121).  In  this  way  the  omentum  cannot  play 
its  customary  part  in  producing  a  recurrence  of  the  hernia  (Fig.  122). 


Fig.  122. — Sac  of  the  preceding,  with  the  liga- 
ture of  the  pedicle  placed  at  the  highest  pos- 
sible point.  After  resection  the  pedicle  O,  by 
retraction  of  the  peritoneum,  ascends  to  O' 
(Championniere). 


Fig.  123. — Sac  closed  by  chain  ligatures 
(Championniere). 


Championniere' s  Operatioji. — First  Step :  Removal  of  the  Sac. — The 
incision  should  be  made  where  it  best  exposes  the  neck  of  the  sac ;  it 
should  not  be  too  short,  for  the  operator  needs  an  abundance  of  room 
to  make  a  complete  dissection  of  the  sac  ;  it  should  be  as  far  away  as 
possible  from  the  scrotum  and  penis,  and  especially  from  the  labia,  to 
guard  against  infection  from  the  secretions  of  these  parts.  The  sac,  par- 
ticularly if  small,  is  often  difficult  to  find;  hence  the  advantage  of  mak- 
ing the  incision  as  high  as  possible  in  the  direction  of  the  inguinal  canal. 
No  matter  how  thin  the  sac  may  be,  an  attempt  should  be  made  to 
dissect  it  out  /;/  toto.  A  pair  of  blunt-pointed  scissors  is  the  best  instru- 
ment. The  sac  must  not  be  too  strongly  drawn  upon,  for  it  will  either 
be  too  firmly  adherent  to  be  separated  from  the  other  tissues,  or  it  will 
be  too  thin  to  stand  the  strain  and  will  tear. 

Whatever  the  hernia  operated  upon,  the  layers  must  be  separated 
one  by  one,  and  the  serous  membrane  isolated  as  much  as  possible 
from  the  neighboring  parts,  in  order  to  carry  dissection  as  far  up  as 
possible.  In  an  acquired  hernia  the  adhesions  may  be  just  as  firm  as 
those  of  a  congenital  hernia.  In  the  latter  variety  the  sac  is  generally 
very  thin.  Having  reached  the  highest  point,  a  strong  ligature  is 
applied  and  the  sac  cut  off  When  the  sac  is  large  it  should  be  tied 
off  with  a  chain  ligature,  as  seen  in  Fig.    123. 

Second  Step  :  Treatment  of  the  Orgaiis  contained  in  the  Hernia. — The 
intestine,  if  healthy,  is  returned  to  the  abdomen,  and  requires  no  further 


266  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

consideration.  The  omentum  is  a  structure  requirinj^f  the  most  careful 
manat^^ement.  It  is  a  dreaded  agent  in  the  formation,  maintenance,  and 
recurrence  of  hernia,  and  should  be  reduced  to  the  smallest  possible 
dimensions.  Not  only  should  the  protruding  omentum  be  removed, 
but  all  that  can  be  drawn  out.  And  when  none  presents  at  the  open- 
ing, the  finger  should  be  passed  up  in  search  of  it  with  a  view  of  draw- 
ing it  down  and  resecting  all  that  can  be  pulled  out.  The  removal  of 
omentum  has  three  advantages  : 

1.  It  empties  the  abdomen  of  part  of  its  contents  and  makes  room 
for  other  viscera. 

2.  It  suppresses  an  organ  which  is  an  active  agency  in  the  formation 
of  hernia. 

3.  This  procedure  allows  us  to  discover  adhesions  at  or  above  the 
neck  of  the  sac  whenever  they  exist.  These  adhesions  are  often  the 
cause  of  the  return  of  the  hernia  and  the  persistence  of  pain. 

Having  broken  up  adhesions  and  brought  down  the  omentum,  it 
should  be  laid  upon  a  sterilized  towel  and  spread  out  until  it  is  in  a 
single  layer,  with  every  vessel  of  any  size  plainly  visible.  De  Garmo 
urges  the  importance  of  numerous  ligatures,  instead  of  the  older 
method  of  tying  off  in  one  or  two  masses.  He  begins  at  one  edge  of 
the  fan-shaped  omentum  as  it  is  spread  out  in  a  single  layer,  and  places 
a  row  of  silk  ligatures  across  to  a  corresponding  point  on  the  opposite 
side.  No  piece  of  fat  larger  than  a  lead  pencil  is  included  within  one 
ligature,  and  every  vessel  that  can  be  seen  is  tied  separately.  The  liga- 
tures are  cut  off  close  to  the  knots,  except  those  at  the  edges,  which 
are  clamped  with  forceps  to  control  the  stump.  The  omentum  is  then 
cut  away,  the  surface  of  the  proximal  portion  is  dusted  with  aristol,  the 
end  ligatures  are  cut  off,  and  the  stump  dropped  back  into  the  abdomen.^ 

TJiird  Step:  CIosui'c  of  the  IVoiDid  to  Secure  a  Firm  Cicatrix. — The 
third  fundamental  condition  of  the  radical  cure  is  the  formation  of  a 
strong  barrier  extending  along  the  whole  hernial  region.  To  secure 
this  the  incision  must  be  long  and  high  up  along  the  inguinal  canal, 
without  sparing  the  lax  muscular  fibers  stretched  by  the  passage  of  the 
viscera.  One  of  the  most  potent  factors  in  the  formation  of  a  strong 
cicatrix  is  asepsis,  for  the  cicatrices  w^hich  are  really  strong,  truly 
resisting,  are  those  that  heal  by  first  intention. 

For  the  deep  suturing  the  best  material  is  kangaroo  tendon.  It  is 
strong,  easily  tied,  and  is  absorbed  in  about  three  months,  the  time 
generally  required  for  the  completion  of  cicatrization.  The  soft  parts 
which  formed  the  wall  of  the  canal  are  first  brought  together,  and 
when  the  hernia  has  been  large  one  side  of  the  canal  should  be  made 
to  overlap  the  other.  This  row  of  sutures  should  include  the  aponeu- 
rosis and  muscles.  The  next  row  can  be  of  catgut,  and  it  unites  the 
cellular  tissue  in  front  of  the  muscle  and  extends  downward  along  the 
cord.  The  last  row  is  made  with  silkworm  gut  and  closes  the  wound 
in  the  skin.  A  drainage-tube  is  placed  in  the  position  farthest  from 
infection,  an  antiseptic  dressing  applied,  and  strong  and  steady  pressure 
maintained  for  three  or  four  days. 

Treatment  of  the  Testicle. — The  testicle  may  occupy  any  of  the 
following  positions  : 

^  Annuls  of  Surgery,  June,  1895. 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE   SYSTEM.        267 


First :  It  may  be  in  the  bottom  of  the  sac,  as  in  congenital  hernia. 
In  this  case  it  is  normally  located,  and  all  we  have  to  do  is  to  provide 
from  the  hernial  sac  a  serous  membrane  to  cover  it.  The  membrane 
may  be  sutured  or  it  may  be  allowed  to  roll  up  around  the  testicle. 

Second :  The  testicle  may  be  in  the  vicinity  of  the  inguinal  canal  or 
in  the  canal  itself  This  condition  is  more  serious.  If  the  patient  is 
not  young"  and  the  testicle  painful,  it  may  be  sacrificed,  but  most 
patients,  even  with  atrophied  testicles,  object  to  this  measure.  The 
testicle  and  epididymis  may  be  so  firmly  adherent  to  the  hernial  sac  that 
it  may  be  very  difficult  to  separate  them.  The  testicle  held  by  fibrous 
bands  is  drawn  upward,  and  held  there  in  spite  of  our  efforts  to  bring 
it  down.  If  the  bands  be  divdded,  the  testicle  will  remain  down,  but 
there  is  no  lodgement  for  it.  Championniere  is  in  the  habit  of  making 
a  new  bed  for  it  by  tearing  through  the  cellular  tissue  of  the  scrotum 
with  his  finger.  When  the  vas  deferens  is  shortened  and  atrophied,  the 
testicle  should  be  sacrificed.  In  his  266  cases  he  has  only  been  com- 
pelled to  perform  castration   5  times. 

Maceivcn's  Operation. — The  steps  of  Macewen's  operation  are  as 
follows : 

(i)  He  forms  a  pad  on  the  abdominal  surface  of  the  internal  ring, 
and  (2)  closes  the  inguinal  canal. 

(i)  The  formation  of  the  pad.  The  bowel  having  been  reduced  in 
the  ordinary  way,  the  sac  is  thoroughly  freed  in  its  whole  extent  from 
the  cord  and  from  the  walls  of  the 
inguinal  canal.  Then  strip  the 
peritoneum  from  the  abdominal 
wall  for  about  two  inches  round 
the  internal  ring  and  fix  a  stitch 
securely  in  the  distal  (/.  e.  the  ab- 
dominal) extremity  of  the  sac.  This 
stitch  is  passed  several  times  through 
the  sac  to  its  outer  extremity,  so 
that  when  drawn  tightly  the  sac  is 


Fig.  124. — Macewen's  operation:  the  sac 
transfi.xed  and  drawn  into  a  fold. 

Fig.  125. — The  sac  as  a  pad  covering 
the  abdominal  aspect  of  the  internal  ring  in 
Macewen's  operation. 


Fig.    126. — Macewen's  operation  :  the   threads 
ready  for  tying. 


folded   up  Hke  a  concertina  (Figs.   124,   125).     The   free   end    of  the 
suture  is  then   threaded  on  a  hernia  needle,  passed  along  the  inguinal 


268  SURGICAL    J) /A GNOSIS  AND    TREATMENT. 

caiKil  and  through  tlic  structures  of  the  abdominal  wall,  from  within 
outward,  one  inch  above  the  ring.  The  skin  is  to  be  drawn  up  out  of  the 
way  while  this  suture  is  being  passed.  The  end  of  the  suture  is  then 
fixed  b\'  introducing  it  several  times  through  the  external  oblique  muscle. 

In  this  way  the  sac  is  not  only  obliterated,  but  forms  a  pad  which 
protects  a  weak  point  in  the  abdominal  wall. 

(2)  The  closure  of  the  inguinal  canal  is  accomplished  in  the  follow- 
ing manner  (Fig.  126) :  The  conjoint  tendon  is  penetrated  in  two  places, 
at  its  upper  and  lower  ends,  by  a  single  thread  of  catgut,  so  that  a  loop 
is  made  with  its  convexity  on  the  abdominal  aspect  of  the  tendon. 
The  lower  freed  end  of  this  thread  is  passed  from  within  outward 
through  Poupart's  ligament,  and  the  upper  end  through  the  external 
oblique  and  transversalis  muscles,  each  stitch  maintaining  the  level  it 
has  at  the  conjoined  tendon.  The  two  free  ends  are  then  tied  in  a  reef 
knot.  The  cord  should  be  examined  before  tightening  each  stitch  to 
avoid  compression. 

The  pad  is  now  considered  an  objectionable  feature,  and  mainly  on 
this  account  Macewen's  operation  has  been  supplanted  by  the  methods 
of  Bassini  and  Halsted. 

BassinYs  Operation. — First  Step. — The  incision  extends  from  a 
point  on  a  level  with  the  anterior  superior  spinous  process  obliquely 
downward  parallel  to  and  about  half  an  inch  above  Poupart's  ligament, 
and  ends  at  the  center  of  the  external  abdominal  ring.  The  dissection 
is  continued  until  the  aponeurosis  of  the  external  oblique  is  reached 
and  exposed  for  a  distance  of  about  three  inches.  A  director  is  then 
passed  beneath  the  aponeurosis  through  the  external  ring,  and  the 
aponeurosis  divided  to  a  point  half  an  inch  or  a  little  more  above  the 
internal  ring.  The  edges  of  the  aponeurosis  are  dissected  backward 
toward  the  middle  line  as  far  as  the  edge  of  the  rectus,  and  outward 
until  the  shelving  portion  of  Poupart's  ligament  is  fully  exposed. 

Second  Step. — The  sac  and  cord  are  isolated  by  the  fingers  and 
blunt-pointed  curved  scissors.  The  cord  and  its  vessel  are  separated 
from  the  sac  and  the  separation  carried  high  up  within  the  internal 
ring. 

Third  Step. — Open  the  sac,  and,  having  separated  adhesions  and 
removed  any  thickened  omentum  that  may  be  present,  return  the  con- 
tents of  the  sac  to  the  abdominal  cavity.  Ligate  the  sac  above  the 
internal  ring  and  cut  it  off  below  the  ligature. 

Fourth  Step. — The  cord  is  held  up  by  a  hook  and  the  edges  of  the 
aponeurosis  kept  out  of  the  way.  Buried  sutures  are  then  placed  so  as 
to  close  the  abdominal  wall  beneath  the  cord.  These  sutures,  three  to 
five  in  number,  should  include  on  the  inner  side  the  internal  oblique 
and  transversalis  muscles,  the  transversalis  fascia,  and  in  some  cases 
the  edge  of  the  rectus,  on  the  outer  side  the  shelving  portion  of  Pou- 
part's ligament.  Replace  the  cord  and  close  the  aponeurosis  over  it  by 
a  continuous  suture.  This  suture  should  begin  as  near  the  pubes  as 
possible  without  constricting  the  cord.  The  wound  in  the  skin  is 
closed  by  interrupted  sutures.     No  drainage  is  necessary. 

Halsted's  Operation. — In  Halsted's  operation  for  the  radical  cure 
of  inguinal  hernia  an  incision  is  made  through  the  skin  from  a  point  5 
cm.  above  and  external  to  the   internal  abdominal  ring,  as  far  as   the 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE   SYSTEM.       269 

spine  of  the  pubis.  Then,  the  aponeurosis  of  the  external  obhque,  the 
internal  oblique,  transversalis  muscles,  and  transversalis  fascia  having 
been  divided  along  a  line  extending  from  the  external  ring  to  a  point  2 
cm.  above  and  external  to  the  internal  ring,  the  cord  is  isolated  and 
reduced  in  size  by  excising  all  the  veins  except  one  or  two.  The  sac 
of  the  hernia  is  next  isolated  and  opened,  and,  its  contents  having  been 
replaced  in  the  abdomen,  the  peritoneal  cavity  is  closed  by  a  few  fine 
silk  mattress  sutures,  and  the  remainder  of  the  sac  cut  off  close  to  the 
sutures.     The  isolated  cord  is  now  raised  on  a  hook  (Fig.  127),  whilst 


Fig.  127. — Inguinal  canal  laid  open  ;  sac  cut  away  after  suture  of  the  peritoneum  ;  elements 
of  cord  isolated  and  lifted  up  ;  deep  mattress  sutures  introduced  :  A,  aponeurosis  of  the  exter- 
nal oblique  muscle  ;  D,  vas  deferens ;  F,  fascia  transversalis  ;  P,  peritoneum  ;  T,  conjoined 
tendon;    V,  vein;    Kf^,  stumps  of  excised  veins   (Halsted). 

Fig.  128. — Deep  sutures  tied  (Halsted). 

the  cut  edges  of  the  incision  through  the  aponeurosis  of  the  external 
oblique,  internal  oblique,  and  transversalis  muscles,  and  transversalis 
fascia  are  again  brought  together  by  six  or  eight  deep  mattress  sutures. 
The  cord  passes  between  the  two  outermost  sutures,  and  care  must  be 
taken  that  the  distance  between  them  is  such  that  the  cord  is  embraced 
without  danger  to  its  circulation.  The  cord  will  now  lie  on  the  surface 
of  the  external  oblique  muscle  under  the  skin  (Fig.  128).  The  skin- 
wound  is  closed  by  silver-wire  sutures. 

Halsted's  operation  is  sometimes  spoken  of  as  a  modification  of 
Bassini's,  but  this  is  not  correct,  as  our  famous  American  confrere 
not  only  arrived  at  his  conclusions   independently  of  the  distinguished 


2/0  SURGICAL   DIAGNOSIS  AND    TR BAILMENT. 

Italian  surgeon,  but  claims  priority  of  publication.  The  two  operations 
differ  in  several  important  particulars.  In  Bassini's  method  the  cord  is 
placed  under  the  aponeurosis  of  the  external  oblique ;  in  Halsted's 
operation  the  cord  is  placed  outside  the  aponeurosis.  Bassini's  ope- 
ration does  not  interfere  with  the  veins  of  the  cord  ;  Halsted  removes 
all  superfluous  veins,  thus  diminishing  the  size  of  the  cord — a  very  im- 
portant consideration.  In  Bassini's  operation  the  obliquity  of  the 
inguinal  canal  is  not  restored ;  it  is  restored  by  Halsted's  method. 

The  Radical  Cure  of  Femoral  Hernia. — The  operation  of  Bassini  of 
Padua  is  probably  the  best.  He  makes  an  incision  parallel  to  Poupart's 
ligament  and  over  the  center  of  the  tumor ;  he  ligates  the  sac  high  up 
and  removes  it.  He  unites  Poupart's  ligament  with  the  pectineal  fascia 
by  three  silk  sutures  which  he  inserts  with  a  curved  needle.  The  first 
is  placed  near  the  spine  of  the  pubes,  the  second  half  a  centimeter  ex- 
ternally, and  the  third  one  centimeter  from  the  femoral  vein.  These 
sutures  are  not  tied  until  four  other  sutures  are  passed  through  the 
edges  of  the  falciform  fascia,  and  then  the  pectoneal  fascia,  the  lower 
suture  entering  just  above  the  saphenous  vein  ;  the  upper  sutures  draw 
Poupart's  ligament  backward  to  the  pectoneal  line  and  close  the  mouth 
of  the  canal.  The  other  sutures  bring  together  the  anterior  and 
posterior  walls  of  the  canal.  The  wound  in  the  skin  is  then  closed, 
and  no  drainage  is  employed. 

Palliative  Treatment  of  Hernia. — As  the  radical  operation  comes 
nearer  and  nearer  to  perfection  fewer  cases  will  require  treatment  of  a 
palliative  kind.  There  are  many  persons  whose  natural  abhorrence  of 
a  cutting  operation  will  lead  them  to  go  through  life  with  the  annoy- 
ance of  a  hernia  and  the  inconvenience  of  a  truss.  Besides,  there  are 
certain  cases  already  stated  which  are  not  amenable  to  the  radical  cure, 
as  old  men  and  children  below  six  years  of  age,  persons  suffering  from 
albuminuria,  diabetes,  etc.,  and  those  who  are  predisposed  to  hernia. 

In  young  children  a  truss  not  only  retains  the  hernia  within  the 
abdomen,  but  in  many  cases  effects  a  permanent  cure.  Hence  in  them 
this  treatment  should  always  be  adopted,  with  the  radical  cure  held  in 
reserve  to  be  brought  into  requisition  if  the  hernia  remains  after  the 
child  has  reached  the  age  of  six  years. 

Persons  who  are  the  subjects  of  hernia  should  avoid  violent  exer- 
cise, sudden  strains,  and  should  prevent  constipation  of  the  bowels. 
For  retaining  a  hernia  in  the  abdominal  cavity  a  truss  is  necessary,  and 
a  great  variety  of  appliances  in  this  direction  have  been  invented.  For 
slight  or  incomplete  hernia,  or  in  persons  who  are  not  obliged  to 
engage  in  laborious  occupations,  an  elastic  truss  is  sufficient,  but  in 
others  trusses  having  a  steel  spring. and  a  pad  composed  of  hard  wood 
or  rubber  are  essential.  The  wearing  of  a  truss  is  attended  with  diffi- 
culty in  the  case  of  fat  people,  in  a  hernia  which  contains  a  portion  of 
irreducible  omentum,  and  in  femoral  hernia.  In  oblique  inguinal  hernia 
the  pad  is  made  to  fit  over  the  internal  inguinal  ring ;  in  direct  inguinal 
hernia  it  fits  over  the  external  ring ;  in  femoral  hernia  over  the  femoral 
ring  at  the  level  of  Gimbernat's  ligament. 

Before  applying  a  truss  it  is  necessary  to  reduce  the  hernia.  This 
is  done  by  placing  the  patient  upon  his  back  with  the  pelvis  elevated. 
The  sac  is  first  emptied  as  described  in  the  employment  of  taxis.     The 


INJURIES  AND   DISEASES   OF   THE   DIGESTIVE   SYSTEM.        2/1 

direction  of  pressure  will  vary  according  to  the  form  of  hernia.  In 
indirect  inguinal  hernia  this  will  be  upward  and  inward.  For  the 
measurement  of  a  truss  a  few  points  must  be  considered  :  the  size  of 
the  aperture,  the  circumference  of  the  pelvis  one  inch  below  the  crest 
of  the  ilium,  the  circumference  of  the  body  below  the  level  of  the 
aperture,  the  distance  of  the  hernial  opening  from  the  anterior  supe- 
rior process,  the  direction  in  which  pressure  is  to  be  applied,  and 
whether  the  hernia  is  single  or  double. 

Umbilical  Hernia. — This  variety  of  hernia  is  found  under  three 
conditions : 

1.  Cong-enital. — Both  male  and  female  infants  are  found  at  birth  to 
be  the  subjects  of  umbilical  hernia,  but  female  children  are  in  the 
majority.  The  hernia  is  due  to  imperfect  closure  of  the  abdominal 
wall,  the  visceral  plates  failing  to  meet  in  the  middle  line.  The  cover- 
ing is  often  exceedingly  thin,  consisting  only  of  the  peritoneum  and 
tissues  of  the  cord,  and  allowing  the  contents  of  the  sac  to  be  plainly 
seen.  These  herniae  are  often  of  immense  size,  and  may  even  contain 
all  the  abdominal  organs.     The  cecum  is  a  frequent  constituent. 

The  trcatmoit  consists  in  reducing  the  hernia  as  soon  as  possible 
after  birth,  and  retaining  it  by  the  use  of  strong  strips  of  adhesive 
plaster  over  which  a  broad  bandage  is  applied.  In  small  herniae  a  small 
pad  is  useful  under  the  strapping. 

The  radical  operation  in  mild  cases  is  seldom  necessary,  as  with 
proper  care  spontaneous  cure  is  the  rule. 

2.  Infantile  umbilical  hernia  is  the  result  of  stretching  of  the 
cicatrix  shortly  after  birth.  The  tumor  is  easily  reduced,  and  can  be 
kept  in  position  by  a  pad  about  the  size  of  a  dollar  and  retained  by  an 
easy-fitting  belt.  Tight  bandaging  and  conical  or  button-shaped  pads 
which  fill  the  opening  are  to  be  condemned.  A  piece  of  adhesive 
plaster  which  is  brought  across  the  hernia  in  such  a  way  as  to  fold  the 
skin  up  into  a  roll  at  each  side  of  the  umbilicus  is  often  satisfactory. 
The  tendency  of  this  form  of  rupture  is  to  get  well  as  the  child 
grows. 

3.  Umbilical  hernia  in  adults  is  most  frequently  met  with  in 
females  who  have  borne  numerous  children.  The  covering  is  generally 
peritoneum  and  skin,  and  the  size  of  the  tumor  may  be  enormous.  It 
may  at  first  escape  observation,  and  one  of  its  first  indications  may  be 
severe  neuralgic  pains  radiating  from  the  umbilicus.  Two  features 
characterize  these  hernise :  they  increase  rapidly,  and  they  readily  form 
adhesions.  In  addition,  the  subjects  are  inclined  to  obesity  and  are 
liable  to  emphysema  of  the  lungs  ;  consequently  the  cough  and  diffi- 
culty of  respiration  react  upon  the  hernia,  causing  its  more  rapid 
increase  in  size  (Championniere). 

Tj'catincnt. — Bandages  here  are  of  little  value.  The  radical  cure 
affords  the  best  prospect  of  a  satisfactory  result.  The  operation  is  to 
be  conducted  on  the  general  principles  already  laid  down,  consideration 
being  given  to  differences  in  anatomical  structure  and  physiological 
action.  The  incision  may  be  straight  or  curved,  the  latter  being  chosen 
when  it  is  desirable  to  lay  open  a  larger  space.  One  end  of  the  incision 
must  be  over  the  hernial  aperture.  In  view  of  the  frequency  of  intes- 
tinal  adhesions  the  sac  must  be  cautiously  opened  and  care  taken  to 


272 


SL'KGICAl.    DUGiVOS/S  AND    TREATMENT. 


avoid  perforating  the  bowel.  \\\  dealing  with  the  omentum  the  hernial 
opening  should  be  freely  enlarged  and  a  free  portion  of  the  omentum 
found  in  the  abdomen.  From  this  point  it  must  be  traced  down  into 
the  sac  and  freed  from  its  adhesions.  The  omentum  is  drawn  gently 
out,  so  that  not  onl)-  the  part  which  was  adherent  to  the  sac,  but  a  por- 
tion that  lay  above  the  hernia,  is  drawn  down,  spread  out  upon  steril- 
ized gauze,  ligated  off  by  chain  ligatures,  and  removed  (Championniere). 
The  sac  is  next  dealt  with.  It  is  freed  from  all  adhesions,  laid  open, 
ligated  by  two,  three,  or  more  chain  ligatures  (as  seen  in  Fig.  123),  and 
cut  off  In  closing  the  abdominal  wound  interrupted  sutures  of  kanga- 
roo tendon  are  placed  in  the  muscular  wall.  A  continuous  catgut 
suture  closes  the  cellular  tissue  and  fascia,  and  lastly  a  row  of  super- 
ficial and  deep  sutures,  alternating,  are  employed  to  close  the  opening 
in  the  skin.  Drainage  is  useful  when  the  abdominal  wall  is  very  much 
thickened  with  fat,  otherwise  it  is  not  indicated. 

Ventral  Hernia. — A  hernia  in  the  linea  alba,  above  or  below, 
but  not  at,  the   umbilicus,  in  the  linea  semilunaris,   or  in  any  other 

part  of  the  abdominal  wall  which 
is  not  a  common  position  of  rup- 
ture, is  spoken  of  as  ventral 
hernia.  Many  of  the  cases  occur 
after  laparotomies  (Fig.  129). 
When  of  considerable  size  these 
herni?e  are  readily  diagnosticated, 
and  their  treatment  is  practically 
that  of  umbilical  hernia.  The 
tumor  may  be  very  small  and 
escape  observation,  and  yet  pro- 
duce very  urgent  symptoms.  This 
is  especially  the  case  when  the 
hernia  contains  omentum,  which, 
forming  adhesions,  is  retained  in 
the  sac.  Sometimes  the  omen- 
tum forms  a  narrow  band  be- 
tween the  stomach  and  the 
hernia.  In  such  cases  the  pain 
and  gastric  disturbances  are  such 
as  to  lead  to  a  suspicion  of  can- 
cer of  the  stomach.  The  band 
usually  goes  to  the  great  curva- 
ture, and  as  a  consequence  intense 
suffering  results  from  movements 
of  the  stomach  or  when  the  organ 
is  distended  with  food  or  gas. 

The  diagnosis  must  rest  upon 
the  presence  of  a  tumor,  however 
small,  which  may  or  may  not  be 
attended  with  an  impulse  on  coughing.  Sometimes  the  presence  of  a 
band  may  be  determined  by  a  drawing  in  of  the  abdominal  wall  at  that 
point.  Violent  attacks  of  gastric  pain  and  vomiting  are  also  common 
consequences. 


Fig.  129. — Large  vt-ntrnl  hernia  forming  in  the 
cicatrix  made  for  removal  of  an  ovarian  cyst. 
The  patient  bore  two  children,  after  which  a 
cyst  formed  in  the  remaining  ovary,  burst 
through  the  cicatrix,  and  filled  the  hernia  (from 
a  photograph  in  the  collection  of  Dr.  W.  J. 
Mayo,  Rochester,  Minn.). 


INJURIES  AND   DISEASES   OF   THE   DIGESTIVE   SYSTEM.        273 

The  treatment  consists  in  the  radical  operation  for  the  hernia  and 
division  of  the  omental  band. 

lylimbar  Hernia. — A  weak  point  in  females  who  have  rapidly  lost 
flesh  is  the  triangle  of  Petit,  formed  by  the  lower  margin  of  the  external 
oblique,  the  latissimus  dorsi,  and  the  crest  of  the  ilium.  Its  floor  is 
formed  by  the  internal  oblique.  The  course  of  a  hernia  in  this  locality 
is  through  the  lumbar  fascia,  near  the  outer  edge  of  the  quadratus 
lumborum  muscle.  Its  interest  from  a  diagnostic  point  of  view  lies  in 
the  danger  of  mistaking  the  hernia  for  tumor  or  abscess — an  error  which 
has  more  than  once  led  to  incision  and  disappointment.  The  history 
of  the  case,  the  occurrence  of  a  reducible  tumor  in  an  emaciated 
female  or  its  connection  with  a  traumatism,  the  presence  of  an  impulse 
on  coughing,  and  the  absence  of  symptoms  of  suppuration  should 
make  the  diagnosis  reasonably  clear.  The  only  treatment  required,  as 
a  rule,  is  a  comfortably  fitting  elastic  abdominal  belt. 

Other  rare  forms  of  hernia  are  the  following  : 

Obturator  hernia,  a  very  rare  form.  The  subjects  are  generally 
above  the  age  of  fifty.  It  is  seldom  diagnosed  during  life  unless  it 
becomes  strangulated.  The  symptoms  resemble  femoral  hernia.  The 
tumor  is  situated  to  the  inner  side  of  the  femoral  vessels  in  both  forms. 
The  most  characteristic  symptoms  are  pain  along  the  course  of  the 
obturator  nerve — that  is  to  say,  along  the  inner  side  of  the  thigh  as 
far  as  the  knee — and  the  presence  of  a  hard  and  tender  swelling  on  the 
inner  side  of  the  thigh,  which  in  certain  cases  can  be  felt  on  vaginal 
examination. 

Treatment. — When  there  is  strangulation,  as  is  generally  the  case 
before  the  hernia  is  recognized,  attempts  at  reduction  by  taxis  should 
be  made,  which,  if  unsuccessful,  should  be  followed  by  herniotomy. 
The  constriction  is  at  the  obturator  foramen. 

Perineal  hernia  is  ver>^  rare,  and  is  generally  due  to  weakness  of 
the  levator  ani  muscle.  The  tumor  is  formed  in  front  of  the  rectum, 
and  in  the  case  of  females  it  may  appear  in  the  vagina  or  labium.  The 
tumor  is  always  reducible,  which  distinguishes  it  from  cysts  or  other 
growths. 

Diaphragmatic  hernia  is  generally  the  result  of  a  severe  trau- 
matism, as  the  passing  of  a  cart-wheel  over  the  abdomen  or  the 
wound  of  a  spear  or  saber.  The  symptoms  are  those  of  internal 
strangulation,  but  in  the  majority  of  cases  death  occurs  from  the 
severity  of  the  traumatism  and  a  diagnosis  can  seldom  be  made.  If 
under  circumstances  which  would  lead  us  to  suspect  rupture  of  the 
diaphragm  we  find  tympanitic  resonance  in  the  precordial  region,  with 
interference  with  the  heart's  action,  or  over  the  pleura,  with  impaired 
respiration,  a  diagnosis  of  diaphragmatic  hernia  will  probably  prove  to 
be  correct. 

VI.  APPENDICITIS. 

Arising  from  the  lower  and  posterior  part  of  the  cecum  is  the 
appendix  vermiformis,  a  rudimentary  form  of  the  elongated  cecum  of 
herbivorous  animals.  Its  length  varies  from  three  to  six  inches,  its 
diameter  is  about  half  an  inch.  Dr.  C.  J.  Ringnell  in  200  autopsies  found 
the  length  to  vary  from  two  and  a  half  to  nine  and  three-quarter  inches. 

18 


274  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

By  a  nicscntcry  of  its  own  it  is  bound  loosely  to  the  back  of  the  cecum, 
in  some  cases  to  both  cecum  and  ileum ;  hence  it  is  easily  stretched  or 
twisted  when  these  portions  of  the  intestines  are  distended  (White).  It 
is  supplied  by  a  sin<^le  artery  whose  caliber  is  so  small  that  stretching 
or  twisting  readily  produces  occlusion. 

The  position  of  the  appendix  is  not  constant. 

1.  It  is  generally  directed  upward  toward  the  termination  of  the 
duodenum,  and  lies  to  the  inner  side  of  the  cecum. 

2.  It  is  directed  downward  to  the  inner  side  of  the  cecum  and  into 
the  right  iliac  fossa. 

3.  It  lies  to  the  outside  of  the  cecum,  directed  upward  toward  the 
right  kidney. 

Much  more  rarely  it  is  directed  downward  below  the  cecum,  or  it 
enters  the  sac  of  a  hernia,  or  runs  directly  inward  to  form  an  attach- 
ment at  the  linea  alba,  as  I  once  saw  in  the  case  of  a  young  man  who 
had  suffered  many  recurrences  of  appendicitis. 

Inflammation  in  the  appendix  is  a  disease  of  common  occurrence, 
and  of  late  years  has  received  a  great  deal  of  attention.  The  terms 
typhlitis,  perityphlitis,  paratyphlitis,  and  appendicular  abscess  have 
almost  become  obsolete,  since  a  constantly  accumulating  mass  of 
evidence  goes  to  show  that  nearly  all  of  the  cases  formerly  classed 
under  these  names  are  due  to  inflammation  of  the  appendix  with  or 
without  suppuration.  To  say  that  there  is  no  such  thing  as  typhlitis 
without  appendicitis  is  to  disregard  clinical  facts.  Lanphear  operated 
on  a  case  of  supposed  appendicitis,  and  found  ulcer  of  the  cecum  with 
perforation  and  perityphlitic  abscess.  The  appendix  was  normal.^  It 
would  probably  be  correct  to  say  that  98  per  cent,  of  cases  of  peri- 
typhlitis are  due  to  inflammation  of  the  appendix. 

The  appendix  is  composed  of  a  serous  peritoneal  covering,  a  mus- 
cular coat,  and  a  mucous  lining  with  a  large  proportion  of  lymphoid 
tissue.  To  the  presence  of  this  lymphoid  tissue  is  perhaps  due  the 
clinical  fact  that  so  many  cases  of  appendicitis  occur  in  childhood  and 
youth. 

The  starting-point  of  appendicitis  is  from  within,  commencing  as  a 
simple  catarrh,  and  producing  no  local  changes  beyond  a  thickening 
of  the  mucous  membrane,  and  perhaps  an  accumulation  of  mucus. 
From  this  point  the  disease  may  recede,  pain,  tenderness,  and  all  other 
symptoms  disappearing.  These  are  the  mild  cases  which  are  often 
pointed  to  as  being  successfully  treated  without  operation.  When  the 
inflammation  results  in  suppuration,  abscess,  and  peritonitis,  we  have 
the  disease  presenting  a  variety  of  features,  which  will  be  spoken  of 
presently  (see  Fig.  130). 

Causes. —  I.  The  presence  of  a  hard  foreign  body  in  the  appendix, 
such  as  a  fecal  concretion,  the  small  seeds  of  fruit,  fragments  of  bone, 
etc.  Although  the  presence  of  a  foreign  body  is  spoken  of  as  the 
most  frequent  cause,  it  is  not  a  common  thing  to  find  such  a  body  in 
cases  operated  upon.     Probably  this  cause  has  been  over-estimated. 

2.  Catarrhal  inflammation  of  the  cecum  and  ascending  colon.  In 
this  class  of  cases  the  inflammation  spreads  by  continuity  of  tissue. 
As  the  mucous  membrane  becomes  swollen  the  orifice  becomes  more 

1  Ann.  of  Ufiiv.  Med.  Sciences,  1895,  C.  35. 


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INJURIES  AND  DISEASES   OF  THE   DIGESTIVE   SYSTEM.       275 

and  more  obstructed,  causing  retention  of  the  natural  secretion  of  the 
appendix. 

3.  As  this  secretion  always  contains  putrefactive  and  pathogenic 
organisms,  the  simple  catarrhal  inflammation  readily  becomes  an 
infective  one  (Barling). 

Once  suppuration  begins,  ulceration  is  a  natural  consequence. 
Ulceration  soon  leads  to  perforation,  and  perforation  to  peritonitis. 
Fortunately,  against  the  effects  of  perforation  Nature  sets  up  her  safe- 
guards. As  the  infective  inflammation  reaches  the  outer  coverings  of 
the  appendix,  adhesions  begin  to  form,  and  the  accumulating  pus  is 
enclosed  within  strong  walls,  which  prevent  the  bursting  of  an  abscess 
into  the  peritoneal  cavity.  Sometimes  the  adhesions  occur  so  promptly 
that  the  perforation  is  sealed,  and  a  return  to  health  takes  place  without 
the  formation  of  an  abscess.  In  cases  still  more  rare  the  inflammation 
spreads  so  rapidly  that  no  barriers  can  be  raised,  and  the  consequence 
is  a  general  peritonitis.  Instead  of  ulceration  of  the  appendix,  the 
inflammatory  action  may  result  in  gangrene.  Pressure  of  the  exudates 
on  the  v^essels  from  without  and  thrombosis  from  within  can  speedily 
cut  off  the  blood-supply  to  the  whole  or  a  part  of  this  functionless 
structure,  which,  at  best,  is  endowed  only  with  low  vitality,  and  with 
its  blood-supply  cut  off  quickly  becomes  gangrenous.  As  predisposing 
causes  typhoid  fever  and  rheumatism  have  been  mentioned.  Age  has 
a  decided  influence,  and  about  50  per  cent,  of  all  cases  occur  between  the 
ages  of  ten  and  twenty-five.     It  is  more  common  in  males  than  females. 

Symptoms. — The  leading  symptoms  around  which  many  others 
group  themselves  are  the  following : 

1.  Severe  localized  abdominal  pain,  generally  felt  in  the  right  iliac 
fossa,  sometimes  over  the  whole  abdomen. 

2.  Tenderness  over  the  position  of  the  appendix  midway  between 
the  umbilicus  and  the  anterior  superior  spine  of  the  ilium.  We  have 
seen  that  the  length  and  position  of  the  appendix  are  subject  to  vari- 
ations. It  is  only  natural,  therefore,  that  corresponding  varieties  should 
be  observed  in  the  location  of  the  symptoms.  For  instance,  in  3  cases 
reported  by  Fowler  pain  was  more  marked  on  the  left  side  of  the  abdo- 
men, especially  at  the  outer  border  of  the  left  rectus.  At  the  operation 
the  appendix  was  found  to  the  left  of  the  rectus.'  Too  much  reliance 
must  not  be  placed  upon  the  presence  or  absence  of  tenderness  at 
McBurney's  point,  for  there  is  no  single  point  that  can  be  definitely 
named  as  the  position  of  the  appendix,  or,  for  that  matter,  of  the 
cecum  itself 

3.  A  rise  of  temperature  to  101°  or  102°  F.  and  a  rapid  pulse. 
This  temperature  is  reached  in  the  first  twenty-four  hours  and  seldom 
goes  beyond.     A  temperature  of  103°  is  very  rare. 

4.  Nausea  and  vomiting. 

These  four  symptoms  we  expect  to  find  in  ev^ery  case  of  appen- 
dicitis. Severe  pain  is  present  because  there  is  inflammation  in  a 
structure  whose  walls  are  dense  and  resisting.  By  reflex  action  this 
pain  is  distributed  widely  over  the  abdomen  through  the  sympathetic 
plexuses.  This  widespread  pain  continues  for  from  one  to  twelve  hours, 
after  which  it  becomes  localized  in  the  right  iliac  fossa. 

^  Ann.  of  Univ.  Aled.  Sd.,  c.  37,  1895. 


2/6  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

Now  comes  tenderness  on  pressure  over  the  appendix.  There  are 
the  rapid  pulse  and  high  temperature  peculiar  to  hectic  fever,  for 
suppuration  is  going  on.  Vomiting  is  present  in  most  cases.  It  may- 
occur  only  once,  and  in  any  case  it  consists  of  the  food  last  taken  and 
of  bile.  Persistent  vomiting  or  persistent  hiccough  is  a  very  unfavor- 
able sign. 

The  patient  generally  lies  in  the  dorsal  position,  with  the  lower 
limbs  extended,  or  the  right  may  be  drawn  up  to  relieve  tension  in  the 
iliac  fossa.  Where  there  is  general  peritonitis  both  limbs  are  drawn  up 
and  the  abdominal  walls  are  rigid. 

5.  Constipation  is  the  rule,  although  diarrhea  has  been  noted  in  a 
few  instances. 

6.  In  about  two-thirds  of  the  cases  a  tumor  is  found  in  the  right 
iliac  fossa.  This  does  not  necessarily  prove  the  existence  of  an  abscess. 
In  some  cases  it  is  the  thickened  appendix,  the  omentum,  and  intestine 
matted  together,  or  it  may  be  the  infiltration  of  the  abdominal  muscles 
and  fascia.  Care  must  be  taken  not  to  mistake  rigidity  of  the  muscles 
for  a  tumor.  Anesthesia  is  a  valuable  aid  in  the  examination,  especially 
in  children,  in  nervous  subjects,  and  in  those  whose  abdominal  walls 
are  thick. 

It  is  customary  to  mention  palpation  by  the  rectum  as  a  means  of 
detecting  the  presence  of  a  tumor.  I  have  never  been  able  to  derive 
any  information  from  this  method,  and  have  long  ceased  to  employ  it. 
The  cases  in  which  such  an  examination  proves  of  any  service  are  prob- 
ably those  in  which  the  appendix  takes  a  direction  downward  into  the 
pelvis. 

Neither  can  we  expect  much  help  from  palpation  of  the  appendix 
itself,  for,  while  it  may  be  possible  to  detect  it  in  the  healthy  subject, 
the  extreme  tenderness  and  swelling  which  attend  appendicitis  will 
render  such  a  measure  impossible  during  an  acute  attack.  In  relapsing 
cases  it  has  proved  valuable  when  employed  during  the  interval  between 
attacks ;  and  Ewald  reports  several  cases  in  which  palpitation  enabled 
him  to  settle  the  diagnosis.  The  pressure  must  be  deep  enough  to 
recognize  the  posterior  abdominal  wall  and  the  brim  of  the  pelvis 
against  which  the  appendix  is  felt.  The  beginning  of  the  appendix  is 
found  a  little  outside  of  a  line  drawn  from  the  umbilicus  to  the  middle 
of  Poupart's  ligament. 

7.  Movements  of  the  bladder  may  produce  pain,  as  in  the  act  of 
micturition. 

Differential  Diagnosis. — Of  the  diseases  from  which  appendicitis 
must  be  distinguished  I  shall  mention  : 

1.  Pelvic  inflammation  in  females.  When  a  mistake  is  made,  it  is 
because  the  surgeon  has  neglected  the  imperative  duty  of  making  a 
vaginal  examination.  A  diagnosis  of  appendicitis  in  a  female  should 
never  be  entertained  until  pelvic  inflammation,  especially  of  the  ovaries 
and  tubes,  has  been  excluded.  This,  as  a  rule,  is  very  simple :  A  fixed 
uterus,  hardness  and  infiltration  of  the  pelvic  floor,  or  enlargement  of 
tube  or  ovary  leaves  no  room  for  doubt. 

2.  Intestinal  obstruction.  Appendicitis  shows  a  rise  of  temperature 
from  the  beginning ;  intestinal  obstruction  of  any  kind  has  a  normal 
temperature  until  peritonitis  has  set  in. 


INJURIES  AND   DISEASES   OF   THE   DIGESTIVE   SYSTEM.        277 

3.  Typhlitis  from  accumulation  of  feces  occurs  in  patients  well 
advanced  in  years ;  there  is  a  doughy,  sausage-shaped  tumor  which 
retains  an  indentation  made  by  the  finger.  The  local  tenderness  is  not 
so  marked  as  in  appendicitis. 

4.  Hepatic  colic.  The  pain  in  hepatic  colic  is  most  intense  at  the 
position  of  the  gall-bladder,  and  radiates  to  the  shoulder  and  the  angle 
of  the  scapula.  In  appendicitis  the  tenderness  may  at  the  outset  be 
widely  diffused,  but  in  a  day  or  two  it  becomes  localized  in  the  right 
iliac  fossa.  A  history  of  repeated  attacks,  one  or  more  of  which  have 
been  attended  with  jaundice,  is  strong  evidence  of  hepatic  colic.  Vom- 
iting is  more  persistent  in  the  latter  disease. 

5.  Renal  calculus  on  the  right  side.  Only  when  the  examination 
of  the  urine  is  negative  and  the  pain  is  not  localized,  or  when  the  pain 
in  appendicitis  radiates  toward  the  os  pubis,  scrotum,  and  testicles,  with 
tenesmus  and  dysuria,  should  there  be  room  for  doubt.  In  such  cases 
a  little  time  will  make  the  symptoms  clearer,  for  the  pain  will  become 
localized  in  the  right  iliac  fossa,  proving  appendicitis,  or  tenderness  will 
be  manifested  ov^er  the  kidney  posteriorly,  pointing  to  the  kidney  as  the 
seat  of  the  affection.  Fowler  gives  the  following  diagnostic  points  in  a 
tabular  form : 


Appendicitis. 

Pain  around  the  umbilicus  and 
in  the  epigastric  region,  not 
radiating  from  these  points  ; 
fixed  painful  point  in  the 
iliac  fossa. 

Greatest  tenderness  in  the 
right  iliac  fossa,  particu- 
larly at  McBurney's  point. 


Vomiting  may  be  present,  but 
is  usually  not  continuous. 

The  bladder  and  testicles  are 
very  rarely  symptomatically 
tender  or  painful. 


Hepatic  Colic. 

Pain  in  the  epigastric  region, 
radiating  to  shoulder  and 
angle  of  scapula,  arising 
from  the  gall-bladder  as 
the  fixed  point. 

Great  tenderness  below  the 
arch  of  the  ribs  ;  slight  ten- 
derness over  gall-bladder. 


Vomiting  frequent,  and  not  to 

be  suppressed. 
Bladder  and  testicles  give  no 

symptoms. 


Renal  Colic. 

Pain  radiating  to  inguinal  re- 
gion and  testicle,  occasion- 
ally to  the  rectum  when  at 
stool ;  also  tenesmus. 

Greatest  tenderness  behind, 
over  the  pelvis  of  the  kid- 
ney; in  front  the  maximum 
point  of  tenderness  is  over 
Poupart's  ligament. 

Vomiting  is  not  a  frequent  nor 
prominent  symptom. 

Bladder  irritable ;  dysuria  and 
tenesmus  of  the  bladder ; 
occasionally  hematuria ; 
testicle  retracted. 


All  cases  of  appendicitis  may  be  divided  into  four  classes : 

First  class,  mild  appendicitis,  in  which  neither  abscess  nor  perforation 
takes  place.  To  this  class  probably  belongs  a  majority  of  all  cases. 
They  are  not  regarded  as  surgical  cases,  and  form  the  basis  of  the 
belief  that  appendicitis  gets  well  without  operation.  The  disease  runs 
a  mild  course ;  the  pain,  local  tenderness,  vomiting,  nausea,  and  fever 
are  not  severe.  The  tumor,  if  present,  is  small,  and  all  the  .symptoms 
abate  in  three  or  four  days. 

Second  class,  appendicitis  attended  with  suppuration  and  the  forma- 
tion of  an  abscess.  This  class  belongs  to  the  surgeon,  and  affords  him 
support  for  the  argument  that  the  proper  treatment  for  appendicitis 
is  an  operation.  The  pain  is  severe,  the  local  tenderness  is  marked, 
there  is  fulness  in  the  right  lower  quadrant  of  the  abdomen,  and  sooner 
or  later  a  tumor  appears  at  the  point  of  tenderness. 

There  are  special  indications  that  suppuration  is  taking  place.  The 
temperature  goes  up  to  101°  or  102°  or  103°  F.  at  night,  and  has  a 


278  SURGICAL   DIAGNOSIS  AND   TREATMENT. 

morning  remission.  In  some  cases  there  is  a  pronounced  chill.  If, 
after  continuing  several  days,  the  temperature  should  go  still  higher, 
it  is  an  indication  that  the  septic  infection  is  spreading  to  new  localities. 
The  pulse  gives  still  more  valuable  information.  If  at  the  end  of  three 
or  four  days  it  continues  to  rise,  reaching  110  or  120,  the  presump- 
tion of  abscess  is  very  strong.  The  tumor  becomes  more  prominent, 
and,  if  allowed  to  take  its  course,  redness  of  the  skin,  bogginess,  and 
fluctuation  may  appear,  leaving  no  doubt  that  an  abscess  has  formed. 

Third  class,  perforating  appendicitis  presents  some  of  the  most  per- 
plexing problems  which  can  confront  the  surgeon.  Its  symptoms  are 
often  obscure,  and,  although  operation  is  acknowledged  to  be  the  only 
treatment  of  any  avail,  the  decision  to  operate  will  often  tax  the  judg- 
ment of  the  most  experienced.  Much  depends  upon  the  position  of 
the  appendix.  If  it  happens  to  lie  to  the  inner  side  of  the  cecum,  per- 
foration is  speedily  followed  by  symptoms  that  might  be  called  explo- 
sive in  their  character — sudden,  unremitting  pain,  tenderness,  and 
tympanitic  distention  over  the  whole  abdomen ;  intense  and  persistent 
vomiting  with  a  pulse  running  up  to  no  or  120,  and  a  temperature 
that  suddenly  bounds  to  102°  or  103°.  When  a  case  belonging  to 
another  class  assumes  this  character,  we  may  strongly  suspect  that 
perforation  has  taken  place. 

When  the  appendix,  by  good  fortune,  lies  to  the  outside  of  or  behind 
the  cecum  or  in  a  peritoneal  pouch,  adhesive  inflammation  plays  an 
important  part.  As  soon  as  a  drop  or  two  of  the  contents  of  the  ap- 
pendix escape  through  a  perforation  the  vicious  fluid  is  fenced  in  by 
adhesions,  and  the  danger  of  general  infection  is  greatly  lessened. 

Those  who  advocate  operative  treatment  for  every  case  of  appendi- 
citis find  in  this  class  their  strongest  argument.  No  matter  how  mild 
a  case  may  be  at  its  outset,  there  always  hangs  over  it  three  terrible 
risks — perforation^  rupture,  and  relapse.  In  the  hands  of  a  good  ope- 
rator an  incision  which  would  reach  the  appendix  is  practically  free 
from  danger.  On  the  other  hand,  perforation  or  rupture  is  almost 
certainly  followed  by  death.  Would  it  not  be  wisdom  to  anticipate 
these  risks  and  choose  the  course  which  affords  the  best  prospect  of 
immediate  cure  and  the  only  safeguard  against  recurrence  ? 

The  operation  in  perforating  appendicitis  is  practically  the  same  as 
in  the  suppurative  form,  except  that  when  there  is  evidence  of  general 
infection  of  the  peritoneum  an  incision  in  the  middle  Hne  will  give  a 
better  outlet.  The  fluid  is  often  a  milk-like  serum  rather  than  pus, 
and  here  irrigation  is  not  open  to  the  same  objection  as  in  other 
classes. 

Fourth  class,  relapsing  appendicitis.  The  appendix,  even  after  a  mild 
attack,  as  well  as  the  surrounding  tissues,  is  more  or  less  changed. 
Adhesions  take  place,  the  tube  may  become  narrow  at  one  or  more 
places,  or  it  may  become  kinked  or  twisted  upon  itself;  all  of  which 
may  lead  to  retention  of  its  secretions  and  render  it  liable  to  future  out- 
breaks of  inflammation.  The  question  of  the  most  opportune  time  to 
operate  in  relapsing  cases  is  a  difficult  one.  Generally  the  patient  set- 
tles the  point  by  appealing  to  us  only  during  an  attack.  This  is 
probably  the  best  time,  but  operations  during  intervals  are,  on  the 
whole,  satisfactory. 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE   SYSTEM.       2'jg 

Bull  has  collected  480  operations  of  this  kind  with  8  deaths,  or  a 
mortality  of  1.77  per  cent.  He  estimates  that  5  or  6  per  cent,  would 
be  more  nearly  correct.' 

Appendicitis  obliterans  has  been  described  by  Prof  Senn  as  forming 
a  class  of  cases  in  which  the  lumen  of  the  appendix  becomes  gradually 
obliterated  by  relapsing  disease.  This  classification  seems  unnecessary. 
In  a  functionless  and  rudimentary  structure  like  the  appendix  oblitera- 
tion would,  a  priori,  be  a  natural  process.  This  assumption  is  borne 
out  by  the  result  of  400  autopsies  made  by  Ribbert  (death  being  due 
to  other  causes  than  appendicitis)  in  which  partial  or  complete  oblitera- 
tion was  found  in  25  per  cent. 

Prognosis. — In  a  total  of  364  cases  Wyeth  calculates  the  mortality 
of  appendicitis  at  18  per  cent.  The  mortality  from  operations  made  in 
the  interval  between  attacks  is  probably  5  or  6  per  cent.  (Bull). 

Treatment. — The  treatment  of  the  first  class  of  cases  is  debatable 
ground.  Granted  that  the  majority  of  all  cases  are  of  this  kind,  and 
that  they  get  well  under  medical  care  in  three  or  four  days,  there  is  still 
the  question  of  recurrence.  An  appendix  which  has  been  the  subject 
of  one  attack  is  a  perpetual  menace. 

According  to  the  statistics  of  Sahli,  Hollander,  Fiirbringer,  Leyden, 
Reavers,  Guttman,  and  Rotter,  90  to  91  per  cent,  of  all  cases  of  peri- 
typhlitis get  well  without  an  operation.  On  the  other  hand,  many 
surgeons  resort  to  operation  as  soon  as  they  make  a  diagnosis,  no 
matter  how  early  in  the  disease  or  how  mild  the  symptoms.  Between 
these  two  extremes  we  must  endeavor  to  find  a  golden  mean. 

The  operation  in  the  hands  of  a  skilful  operator  has  a  low  mortality; 
but  another  consequence  of  surgical  interference  must  be  taken  into 
account,  and  that  is  the  risk  of  hernia.  On  the  other  hand,  every  case 
treated  without  operation  has  to  run  the  risk  of  possible  rupture  during 
the  attack  and  of  relapse  after  the  patient  recovers. 

The  third  day,  at  the  latest,  should  decide  the  question.  If  by  that 
time  the  symptoms  are  abating,  do  not  operate,  but  watch  the  case 
closely.  If  on  the  third  day  the  case  continues  to  grow  worse  or  shows 
no  signs  of  improvement,  operate.  In  spite  of  every  care  there  are 
cases  in  which  grave  doubts  must  exist  as  to  the  propriety  of  operation ; 
but,  as  Helfrich  tersely  expresses  it,  "  It  is  always  better  to  say,  '  The 
patient  might  hav^e  recovered  without  operation,'  than  to  say,  '  The 
patient  might  have  been  saved  by  operation.' " 

There  are  certain  indications  for  operation  which  the  most  con- 
servative physicians  will  admit :  First.  When  there  is  perforation 
followed  by  peritonitis.  Many  of  these  cases  are  the  penalty  of  ultra- 
conservatism.  Second.  When  there  is  evidence  of  a  collection  of  pus. 
Third.  When  there  are  the  current  attacks  increasing  in  frequency 
and  severity. 

In  the  early  stages  of  all  classes  of  cases  the  first  essential  is  perfect 
rest  in  bed.  The  horizontal  position  should  be  persistently  maintained, 
the  patient  not  being  allowed  to  get  up  for  micturition,  defecation,  or 
for  any  other  cause.  The  diet  should  be  easil}^  digested  fluids.  The 
practice  of  giving  a  purgative  should  be  condemned.  Fecal  impac- 
tion in  the  cecum  is  not  so  common  as  was  formerly  supposed ;  hence 

'  Ann.  of  Univ.  Med.  Sciences,  1895. 


28o  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

a  purgative  to  remove  impaction  is  unnecessary.  The  better  course 
is  to  relieve  the  bowel  by  enemata  without  causing  much  distention. 
Warm  fomentations  locally  afford  great  relief  When,  in  spite  of 
these  measures,  pain  is  very  severe,  the  indication  is  not  to  give  opium, 
but  to  operate. 

In  the  second  class  of  cases  (those  attended  with  suppuration  and 
abscess)  the  proper  course  is  undoubtedly  to  operate.  Wyeth  states 
that  in  his  entire  experience  he  has  yet  to  see  a  death  which  could  not 
be  properly  ascribed  to  delay  in  timely  and  skilful  surgical  interference. 
The  diagnosis  of  pus  may  be  confidently  made  when  the  tumor  begins 
to  increase,  the  temperature  showing  morning  remissions  and  the  local 
tenderness  persistent.    Fluctuation  and  edema  should  not  be  waited  for. 

The  operation  for  appendicitis  is  performed  as  follows :  An  incision 
is  made  in  an  oblique  direction  through  the  skin,  crossing  a  line  drawn 
from  the  antero-iliac  spine  to  the  umbilicus,  nearly  at  a  right  angle  and 
one  inch  from  the  iliac  spine  (McBurney).  This  is  in  the  direction  of 
the  fibers  of  the  external  oblique,  which  can  be  separated  without  cut- 
ting. The  wound  is  now  held  open  by  retractors,  and  divisions  of  the 
internal  oblique  and  transversalis  effected  in  a  similar  manner  along  the 
direction  of  their  fibers.  The  advantage  of  this  mode  of  dividing  the 
abdominal  wall  is  that  the  action  of  the  muscles  tends  to  close  rather 
than  retract  the  edges  of  the  wound ;  hence  the  chances  of  subsequent 
hernia  are  greatly  lessened.  It  is  only  suitable,  however,  in  simple 
cases  without  suppuration. 

The  position  of  the  incision  in  suppurative  cases  must  depend  upon 
circumstances.  It  should  be  oblique  and  over  the  most  prominent  part 
of  the  tumor.  Two  inches  in  length  is  sufficient  in  most  cases,  though 
others  will  require  three  or  four  inches.  Pus  wells  up  as  soon  as  the 
abscess  is  reached.  The  patient  should  be  turned  on  to  his  right  side, 
and  the  abscess-cavity  mopped  out  with  gauze.  Irrigation  should  not 
be  employed,  le.st  septic  matter  be  carried  into  the  general  peritoneal 
cavity.  Having  evacuated  the  pus,  the  finger  is  passed  into  the  wound, 
and  search  made  for  the  appendix  and  for  foreign  bodies.  The  ana- 
tomical guide  to  the  appendix  is  the  anterior  longitudinal  band  of 
muscle  in  the  cecum  which  leads  to  the  base  of  the  appendix.  When 
the  appendix  is  found,  it  should  be  ligated  near  the  cecum  and  removed. 
If  it  does  not  appear  readily,  no  lengthened  search  should  be  made  for 
it,  as  drainage  of  the  abscess-cavity  will  be  sufficient  to  dispose  of  all 
necrotic  tissue,  including  the  diseased  appendix.  The  cavity  should  be 
drained  from  the  bottom,  either  by  strips  of  iodoform  gauze  or  by  a 
good-sized  drainage-tube,  around  which  gauze  should  be  packed.  The 
wound  can  be  materially  reduced  in  size  by  inserting  a  few  silkworm- 
gut  sutures,  leaving  sufficient  room  in  the  most  convenient  place  for 
drainage. 

In  the  after-treatment  of  cases  operated  for  appendicitis  I  would 
draw  attention  to  two  points : 

I.  Fecal  Fistula. — This  is  a  complication  which  is  likely  to  arise 
when  the  operation  has  been  delayed  till  a  large  abscess  has  formed  or 
when  the  drainage  is  not  thorough.  To  the  young  or  inexperienced  ope- 
rator the  escape  of  intestinal  gases  from  the  wound  or  the  appearance 
of  fecal  matter  therein  is  perfectly  appalling.     Experience,  however, 


INJURIES  AND   DISEASES    OF   THE   DIGESTIVE   SYSTEM.        28 1 

has  proved  that  such  fistulae  close  of  their  own  accord,  and  all  that  is 
needed  is  a  little  patience  on  the  part  of  the  surgeon  and  the  afflicted  one. 
2.  Deficient  Drainage. — It  may  happen  that  after  the  operation  the 
symptoms  improve,  and  eveiything  appears  to  point  to  a  favorable 
issue,  but  at  the  end  of  a  day  or  two  the  temperature  rises,  the  pulse 
increases  in  frequenc}',  pain  returns,  and  the  abdomen  becomes  tym- 
panitic. These  symptoms  indicate  either  the  retention  of  pus  or  the 
formation  of  an  abscess  in  a  new  location.  The  proper  course  to 
follow  under  such  circumstances  is  to  pass  the  finger  into  the  opening 
and  break  up  any  adhesions  that  may  have  formed  since  the  operation. 
You  will  generally  find  one  or  more  pus-cavities.  In  one  case  of 
appendicitis  I  opened  up  the  wound  three  times  in  this  manner,  and 
saved  the  patient's  life.  Sometimes  nature  comes  to  the  patient's  relief 
by  allowing  the  concealed  abscess-cav^ity  to  discharge  into  the  bowel, 
and  thence  per  viavi  naturalcin. 

VII.    DISEASES   AND   INJURIES  OF  THE  PERITONEUM. 

The  peritoneum  is  a  serous  membrane  almost  equal  to  the  skin  in 
its  extent.  While  the  skin  is  an  organ  which  throws  off  waste  material, 
the  peritoneum  absorbs  the  fluids  with  which  it  comes  in  contact, 
readily  disposing  of  large  quantities,  and  showing  no  discrimination 
between  poisonous  and  benign  substances.  Hence  septic  or  poisonous 
fluids  are  readily  taken  up  and  carried  to  the  general  circulation.  The 
free  movements  of  the  membrane  have  also  an  important  clinical 
bearing.  It  slides  over  the  abdominal  organs,  and  its  own  surfaces 
ghde  smoothly  over  one  another,  so  that  an  infection  which  at  first  is 
purely  local  is  likely  to  become  general  in  a  short  time.  Another 
important  characteristic  of  the  peritoneum  is  the  readiness  with  which 
it  forms  adhesions.  Thanks  to  this  power,  septic  foci  are  walled  off 
and  the  success  of  many  surgical  operations  is  assured. 

So  closely  is  the  peritoneum  associated  with  many  of  the  abdominal 
organs  that  disease  of  these  viscera  is  almost  certain  to  extend  to  the 
serous  membrane. 

Examination  of  the  peritoneum  is  very  satisfactorily  conducted  by 
inspection,  palpation,  and  percussion..  In  a  systematic  examination  the 
following  questions  should  be  settled  : 

I.  Is  the  peritoneum  distended? 

Two  conditions  can  produce  distention  of  the  peritoneum — viz. 
escape  of  gas  from  the  stomach  or  intestine  and  a  collection  of  fluid — 
ascites.  Escape  of  gas  into  the  peritoneal  cavity,  technically  named 
meteorismus  peritonei,  is  always  to  be  regarded  as  a  very  serious  matter, 
and  always  leads  to  peritonitis.  The  abdomen  is  distended  and  tym- 
panitic, the  pitch  varying  according  to  the  degree  of  tension.  This, 
however,  can  be  said  of  tympanites  from  gas  within  the  intestine. 
How,  then,  are  we  to  decide  the  question  as  to  whether  the  gas  is  con- 
tained in  the  intestine  or  free  in  the  peritoneal  cavity  ?  By  percussion 
over  the  liver  and  spleen.  If  the  gas  be  free  in  the  peritoneal  cavity,  it 
will  come  in  front  of  these  solid  organs,  and  there  will  be  no  liver  or 
splenic  dulness.  If  it  is  contained  within  the  bowels,  liver  and  splenic 
dulness  will  be  present.     The  liver  may  be  displaced  upward  by  the 


282  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

distended  intestines,  but  it  will  nevertheless  be  recognized  by  dul- 
ness. 

When  free  fluid  in  the  cavity  is  the  cause  of  distention  it  gravitates 
to  the  most  dependent  parts.  At  the  beginning  it  is  confined  to  the 
peh-is  (while  the  patient  is  standing),  and  gradually  rises  until  it  gives 
a  dull  area  and  produces  bulging  in  the  lower  part  of  the  abdomen. 
When  the  patient  lies  upon  his  back  the  fluid,  gravitating  to  the  most 
dependent  parts,  causes  the  sides  to  bulge  outward,  while  the  intestines 
and  stomach  float  like  air-balloons  upon  the  water,  and  give  a  tym- 
panitic note  in  the  anterior  portion  of  the  abdomen.  Ask  the  patient 
to  lie  upon  one  side  and  then  on  the  other,  and  in  each  case  the  fluid 
will  settle  to  the  lowest  part,  and  give  a  dull  percussion-note,  while  the 
intestines  as  promptly  float  and  give  a  hollow  sound. 

Fluctuation  or  undulation  is  another  important  feature  of  ascites. 
Place  one  hand  flat  upon  the  abdomen,  and  with  the  fingers  of  the 
other  hand  gently  tap  the  abdominal  wall  at  a  distant  point,  and  the 
waves  of  fluid  can  be  felt  and  even  seen.  In  people  whose  abdominal 
walls  and  omentum  are  loaded  with  fat  there  is  a  tremulous  movement 
which  may  be  mistaken  for  true  fluctuation.  When,  owing  to  a  large 
amount  of  fluid,  there  is  much  distention,  it  may  be  impossible  to  elicit 
fluctuation. 

If  fluid  be  present,  it  is  either  free  or  encysted.  When  free  the  ease 
with  which  it  gravitates  to  the  dependent  parts  is  very  characteristic. 
When  encysted  there  is  a  feeling  as  if  a  ball  were  grasped  within  the 
hand,  or  the  tumor  formed  by  the  encysted  fluid  may  have  an  elonga- 
ted form ;  tension  is  usually  greater,  and  consequently  fluctuation  is 
indistinct.  Cystic  ovaries,  the  pregnant  uterus,  and  a  distended  bladder 
all  rise  in  front  of  the  abdomen,  pushing  the  intestines  back,  and  when 
the  patient  lies  on  the  back  the  front  yields  a  dull  sound  (Fagge). 

2.  Is  the  peritoneum  inflamed  ?  Peritonitis,  or  inflammation  of 
the  peritoneum,  is  generally  described  as  primary  and  secondary,  but 
the  opinion  is  gaining  ground  that  most  if  not  all  cases  are  of  secondary 
origin.  That  is  to  say,  there  are  no  cases  of  idiopathic  peritonitis, 
there  being  an  exciting  cause  in  every  instance,  the  recognition  of 
which  is  essential  to  a  rational  line  of  treatment.  The  disease  is  also 
divided  into  acute  and  chronic  varieties. 

Surgically,  we  are  deeply  interested  in  peritonitis  on  account  of  its 
frequency  after  many  operations,  such  as  celiotomy,  lithotomy,  lith- 
otrity,  and  litholapaxy.  We  also  meet  with  it  as  an  extension  of 
disease  or  injury  from  the  abdominal  viscera.  A  perforation  of  the 
stomach  or  intestines  with  escape  of  contents  is  with  certainty  followed 
by  general  peritonitis.  Septic  infection  can  travel  up  the  uterine  canal 
and  by  way  of  the  Fallopian  tubes  gain  access  to  the  peritoneum.  A 
perforating  appendicitis  is  responsible  for  many  cases  of  peritonitis. 

Plastic  Peritonitis. — A  very  interesting  feature  about  the  peri- 
toneum is  its  power  to  protect  itself  and  other  structures  by  throwing 
out  plastic  material  which  acts  as  a  barrier  to  advancing  disease  or 
infection.  This  should  not  be  classed  as  an  inflammation,  but  rather  as 
a  regenerative  process.  Should  the  peritoneum  be  wounded  or  bruised 
or  irritated  by  chemical  substances,  without  the  presence  of  septic 
infection,  the  result  is  generally  purely  local.     The  action  of  the  peri- 


INJURIES  AND   DISEASES   OF   THE  DIGESTIVE   SYSTEM.       283 

toneum  is  at  once  changed,  so  that,  instead  of  absorbing,  it  secretes, 
and  its  secretion  is  fibrinous  material,  which  becomes  organized  and 
forms  adhesions  between  portions  of  the  peritoneum  itself  or  serves  to 
bind  the  membrane  to  neighboring  organs.  These  adhesions  may 
afterward  be  absorbed  or  they  may  remain  as  permanent  structures. 

Examples  of  non-septic  peritonitis  are  met  with  in  aseptic  wounds  or 
other  traumae  of  the  peritoneum,  the  application  of  chemical  irritants, 
the  twisting  of  the  pedicle  of  a  tumor,  the  escape  of  aseptic  contents  of 
an  ovarian  tumor,  and  the  strangulation  of  a  hernia. 

This  form  of  peritonitis  being  generally  localized,  the  symptoms 
which  manifest  its  presence  are  localized  pain  and  tenderness,  rigidity 
of  the  abdominal  lua/l  at  that  point,  and  the  presence  of  more  or  less 
fever.  The  rise  of  temperature  is  due  to  resorption,  the  fermentative 
fever  so  commonly  seen  after  operations,  and  in  no  way  connected 
with  suppuration.  The  symptoms  appear  in  from  six  to  thirty-six 
hours  after  the  receipt  of  an  injury.  Collapse  may  at  first  mask  the 
symptoms  of  peritonitis,  but  they  become  apparent  when  reaction 
sets  in. 

The  treatment  of  non-septic  peritonitis  consists  in  perfect  rest  in  the 
recumbent  posture,  the  use  of  hot  fomentations  and,  if  necessary, 
opiates. 

Septic  Peritonitis. — Two  things  are  necessary  to  produce  septic 
peritonitis  :  first,  the  entrance  of  bacteria,  and  second,  the  peritoneum 
must  have  lost  its  absorptive  power.  The  JiealtJiy  peritoneum  has  a 
marvellous  power  of  absorbing  and  disposing  of  bacteria,  so  that  con- 
siderable numbers  of  germs  can  enter  the  peritoneal  cavity  without 
producing  septic  inflammation ;  but  let  the  membrane  once  lose  its 
power  of  absorption,  and  infection  readily  takes  place. 

The  bacteria  which  are  generally  found  in  such  infections  are  the 
pyogenic  germs,  but  the  common  colon  bacillus  is  so  frequently  present 
in  cases  of  intestinal  origin  that  some  have  thought  it  of  diagnostic 
importance.  Bacteria  which  produce  peritonitis  are  sometimes  spoken 
of  as  specific  and  non-specific.  Of  the  specific  germs,  the  tubercle 
bacillus  occupies  a  most  important  position.  The  infection  of  syphilis 
seldom  figures  as  a  cause  of  peritonitis.  Of  the  non-specific  organisms, 
the  pyogenic  germs  are  most  commonly  found.  Even  they  cannot 
produce  peritonitis  except  when  the  amount  of  fluid  which  they  con- 
tain is  so  great  and  the  germs  are  produced  so  rapidly  that  the  tissues 
cannot  deal  with  them  (Grawitz).  This  comes  back  to  the  second 
essential  already  stated,  an  inadequacy  of  the  absorptive  power  of  the 
peritoneum.  The  bacteria  reach  the  peritoneal  cavity,  either  directly 
through  an  opening  in  the  abdominal  wall,  as  in  celiotomy,  or  from 
parts  which  are  covered  by  peritoneum  and  communicate  with  the 
exterior  of  the  body,  as  the  intestinal  canal  and  the  genito-urinary 
tract ;  or  they  may  find  their  way  upward  through  the  open  mouths 
of  the  Fallopian  tubes,  as  is  demonstrated  in  that  terrible  disease,  puer- 
peral peritonitis ;  or  it  is  possible  that  they  may  come  from  remote 
points  of  the  body,  carried  through  one  or  more  of  the  innumerable 
blood-  or  lymph-channels. 

The  peritoneum  may  lose  its  power  of  absorption,  and  thus  supply 
the  second  essential — {a)  by  being  bruised  or  wounded,  {b)  by  being  the 


284  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

seat  of  a  pre-existing  disease,  or  (r)  by  disease  spreading  from  an  organ 
to  the  peritoneum  which  covers  that  organ.  Both  of  the  essentials  are 
well  illustrated  in  perforation  of  the  intestine ;  numberless  bacteria  are 
admitted  to  the  peritoneal  cavity,  and  the  rupture  which  lacerates  the 
peritoneum  deprives  it  of  its  absorptive  power. 

Sy)npto})is. — Pain  is  the  most  prominent  of  all  the  evidences  of  peri- 
tonitis. In  cases  due  to  perforation  of  the  stomach  or  intestine  the 
patient  may  declare  that  the  pain  set  in  with  a  tearing  sensation.  It  is 
nearly  always  sudden,  and  in  most  cases  intense,  cutting,  or  griping. 
The  slightest  motion  aggravates  it,  and  the  unhappy  sufferer  guards 
against  even  such  innocent  movements  as  coughing  or  breathing,  while 
vomiting  is  perfect  torture.  To  guard  against  the  slight  motion  of  the 
abdominal  muscles  he  draws  his  limbs  up  in  bed,  flexing  the  thighs 
upon  the  abdomen.  So  tender  is  he  to  pressure  that  the  weight  of  his 
bed-clothes  is  unbearable,  and  the  idea  of  examining  his  belly  by 
manipulation  fills  his  soul  with  horror.  The  fixation  of  his  abdominal 
muscles  causes  him  to  resort  entirely  to  thoracic  respiration,  and  the 
chest  rises  and  falls  while  the  abdomen  is  perfectly  still.  The  diaphragm 
cannot  descend  without  producing  pain ;  consequently  the  breathing  is 
rapid  and  shallow,  reaching  as  high  as  forty,  fifty,  or  even  sixty,  instead 
of  eighteen  or  twenty,  in  the  minute.  It  is  scarcely  necessary  to  press 
upon  the  abdominal  wall  to  look  for  tenderness.  If  you  need  to  do  so, 
lay  the  hand  gently  upon  the  abdomen  and  watch  the  expression  of  the 
patient's  face,  which  will  indicate  pain  before  he  can  express  his  sensa- 
tions in  words.  Sooner  or  later  the  abdomen  begins  to  swell  and 
becomes  tympanitic ;  hiccough  is  not  uncommon ;  quantities  of  dark- 
colored  liquid  are  raised  from  the  stomach  without  effort  or,  it  may  be, 
expelled  by  distressing  vomiting.  Pinched  and  anxious  from  the  first, 
the  face  assumes  a  ghastly  appearance ;  the  eyes  become  sunken  ;  the 
pulse  becomes  more  and  more  feeble,  and  may  be  imperceptible  at  the 
wrist  for  twenty-four  hours  before  the  end.  The  condition  of  collapse 
supervenes  and  death  closes  the  scene,  the  mind  in  many  cases  remain- 
ing clear  until  the  last. 

When  the  body  is  examined  after  death  little  change  is  seen  in  the 
appearance  of  the  peritoneum,  and  a  small  amount  of  serous  fluid  is  all 
that  is  found  in  the  cavity.  But  this  fluid  is  intensely  poisonous.  Shun 
it  as  you  would  the  venom  of  a  rattlesnake.  Such  is  the  form  of  peri- 
tonitis seen  in  that  awful  disorder  puerperal  fever,  and  also  after  some 
abdominal  operations. 

When  fully  developed,  septic  peritonitis  is  almost  absolutely  certain  to 
prove  fatal,  and  the  most  we  can  do  is  to  palliate  the  patient's  sufferings. 
In  the  universal  rush  to  the  operating-table  these  cases  have  not  been 
made  an  exception,  but,  so  far  as  my  experience  and  observation  have 
gone,  abdominal  section  and  unlimited  flushings  have  proved  of  little 
avail.  In  the  way  of  prevention,  however,  which  is  so  much  better 
than  cure,  there  is  everything  to  be  hoped  for.  As  accoucheurs  form 
the  habit  of  attending  confinements  with  as  strictly  aseptic  precautions 
as  they  would  conduct  a  major  operation,  as  nurses  abandon  filthy 
syringes  and  learn  to  hQ  surgically  clvau,  septic  peritonitis  will  gradually 
but  surely  disappear. 

After  abdominal  section  it  is  not  uncommon  to  find  tympanites  set- 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE   SYSTEM.       285 

ting  in,  which  may  possibly  be  the  beginning  of  septic  peritonitis. 
Experience  has  shown  that  the  best  treatment  in  such  a  case  is  the 
administration  of  a  saHne  cathartic,  such  as  a  Seidlitz  powder  or  a  one- 
grain  pill  of  calomel,  every  three  hours  till  the  bowels  move.  Such  a 
course  is  often  rewarded  by  finding  at  the  next  visit  a  perfectly  flat 
abdomen  and  a  happy  patient. 

Suppurative  peritonitis  is  practically  the  same  disease  as  septic 
peritonitis,  the  only  difference  being  that  in  the  suppurative  form  the 
process  is  less  rapid,  and  pus  has  time  to  form  either  in  localized 
abscesses,  walled  off  by  adhesions,  or  in  one  large  collection  in  the 
general  peritoneal  cavity.  Septic  peritonitis  is  general,  and  results  in 
death  before  suppuration  has  time  to  declare  itself  Suppurative  peri- 
tonitis is  more  likely  to  be  localized,  and  is  therefore  more  amenable  to 
surgical  treatment.  Pain  is  very  severe ;  there  is  usually  a  chill  to 
usher  in  the  disease;  and  the  temperature  rises  to  102°  or  104°  F. 
In  perforative  cases  gases  in  large  quantities  collect  in  the  cavity, 
causing  distention  of  the  peritoneum,  and  are  recognized  by  absence  of 
liver  and  splenic  dulness,  as  already  mentioned.  When  pus  collects  in 
considerable  quantity,  its  presence  can  be  detected  by  dulness  on  per- 
cussion in  the  most  dependent  portions,  just  as  in  the  case  of  ascites. 
Vomiting  and  constipation  are  the  most  characteristic  symptoms,  and 
so  pronounced  are  they  that  we  often  have  to  decide  the  question  as 
to  whether  the  case  is  suppurative  peritonitis  or  intestinal  obstruction. 
To  do  so  we  must  remember  that  in  obstruction  a  tumor  may  be  felt, 
the  movements  of  the  intestinal  coils  can  be  seen  through  the  abdom- 
inal walls,  the  temperature  is  not  high  from  the  beginning,  and  as  time 
goes  on  the  vomiting  becomes  fecal  in  character.  Temperature  is  not 
an  infallible  guide,  for  while  the  rule  is  that  in  peritonitis  it  is  high  and 
in  obstruction  not  raised  above  normal  (except  there  be  complications), 
some  of  the  worst  cases  of  peritonitis  are  free  from  a  rise  of  tempera- 
ture throughout  their  course. 

Treatment. — To  guard  against  suppurative  peritonitis  the  greatest 
care  must  be  observed  in  the  details  of  all  abdominal  operations. 
Asepsis  must  be  observed  most  scrupulously,  the  peritoneal  toilet  must 
not  be  lost  sight  of,  complete  arrest  of  hemorrhage  must  be  ensured, 
and  the  cavity  dried  with  aseptic  sponges.  Should  there  be  infection 
already  established  or  a  likelihood  of  a  collection  of  serous  or  sanguin- 
eous fluid,  a  drainage-tube  must  be  employed.  At  the  slightest  indi- 
cation of  peritonitis  a  saline  cathartic  should  be  given,  the  action  of 
which  is  increased  by  the  use  of  turpentine  enemata.  Opium  in  such 
cases  is  to  be  avoided. 

Perforative  peritonitis  requires  a  somewhat  different  line  of  treat- 
ment. It  would  make  matters  worse  were  we  to  increase  the  peristaltic 
action ;  consequently,  purgatives  of  every  kind  must  be  avoided  and  a 
judicious  use  of  opium  resorted  to.  If  a  diagnosis  of  perforation  be 
made,  the  repair  of  the  perforation  by  operative  measures  should  be 
attempted.  With  this  object  in  view  an  incision  is  made  in  the  linea 
alba,  unless  the  point  of  the  disease  can  be  located  elsewhere.  If  the 
opening  in  the  intestine  cannot  be  readily  found,  recourse  should  be 
had  to  the  hydrogen-gas  test.  The  rent  is  to  be  closed  by  sutures,  as 
already  described  under  Rupture  of  the  Bowel,  the  abdominal  cavity 


286  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

thorouglily  flushed  with  Thiersch's  solution,  a  drainage-tube  inserted, 
and  the  wound  closed  and  dressed. 

Fibro-plastic  peritonitis  is  a  variety  characterized  by  a  tendency  to 
numerous  adhesions.  The  disease  is  probably  identical  with  septic 
peritonitis,  except  that  there  is  not  a  general  intoxication  of  the  system 
by  ptomains,  owing  to  a  less  violent  character  of  the  bacteria  or  a 
greater  resisting  power  of  the  system.  It  commonly  terminates  in 
localized  suppuration. 

Tubercular  Peritonitis. — Tuberculosis  may  attack  the  peritoneum 
simultaneously  with  other  structures,  such  as  the  lungs,  the  bones,  or 
the  joints.  These  cases  are  not  of  surgical  interest.  It  is  also  a  fact 
that  the  peritoneum  may  be  attacked  primarily,  and  remain  the  only 
seat  of  the  disease.  In  this  form  it  is  of  the  greatest  interest  to  the 
surgeon,  since  it  has  been  found  amenable  to  treatment  in  a  very 
satisfactory  degree. 

The  disease  is  not  limited  to  any  particular  period  of  life,  but  follows 
pretty  much  the  same  law  as  tuberculosis  of  the  lungs,  the  majority  of 
cases  occurring  between  the  ages  of  twenty  and  forty.  In  the  diagnosis 
of  tubercular  peritonitis  we  must  not  expect  to  find  the  disease  follow^- 
ing  a  uniform  course  in  every  case.  Osier  makes  the  following  classifi- 
cation : 

1.  Acute  miliary  tuberculosis,  characterized  by  a  sudden  onset,  a 
rapid  development,  and  a  serous  or  sero-sanguineous  exudation. 

2.  Chronic,  caseous,  and  ulcerating  tuberculosis,  characterized  by 
larger  tuberculous  growths  which  tend  to  caseate  and  ulcerate,  leading 
often  to  perforation  between  the  intestinal  coils,  and  by  a  purulent  or 
sero-purulent  exudation,  often  sacculated. 

3.  Chronic  fibro-tuberculosis,  which  may  be  subacute  from  the  out- 
set, or  it  may  be  the  termination  of  the  miliary  form.  This  variety  is 
attended  with  slight  exudation  if  any.  The  tubercles  are  hard  and  pig- 
mented. Although  this  classification  is  based  on  a  correct  pathology, 
w^e  have  no  means  by  which  we  can  differentiate  from  a  clinical  stand- 
point. 

The  diagnosis  of  tubercular  peritonitis  is  not  always  easy.  Bearing 
in  mind  the  manner  in  which  tuberculosis  acts  elsewhere,  we  are  pre- 
pared to  find  it  following  a  slow  and  chronic  course.  There  are  cases, 
however,  in  which  its  development  is  rapid.  We  may  reasonably  look 
for  the  leading  symptoms  by  which  we  detect  ordinary  peritonitis — viz. 
pain,  tenderness,  tympanites,  fever,  etc. — but  these  have  not  here  the 
significance  which  attaches  to  them  in  the  other  varieties  of  peritonitis. 
They  may  be  sudden  in  their  onset,  or  they  may  come  on  so  slowly 
that  distention  of  the  abdomen  is  the  first  symptom  to  attract  attention. 
All  the  symptoms  may  be  apparent  at  one  time,  and  then  subside. 
This  is  just  like  tuberculosis,  for  do  we  not  find  in  pulmonaiy  phthisis 
that  a  patient  has  his  periods  of  improvement  and  decadence?  Pain  is 
usually  slight,  but  in  exceptional  cases  very  severe,  and  tenderness 
to  pressure  is  in  direct  proportion.  The  temperature  is  also  variable. 
As  a  rule,  there  is  little  elevation,  and  generally  we  find  it  in  proportion 
to  the  pain  and  tenderness.  Enlargement  of  the  abdomen  may  be  due 
to  ascites  or  to  meteorism  or  both.  Should  peritoneal  adhesions  take 
place,  collections  of  fluid  may  thus  be  encapsulated,  giving  the  appear- 


v\ 


INJURIES  AND   DISEASES   OF   THE   DIGESTIVE   SYSTEM.        287 

ance  of  cystic  tumors.  Even  when  the  distention  is  due  to  meteorism, 
round  elastic  tumors  can  be  felt,  which  do  not  change  their  position 
when  the  patient  is  moved  to  one  side  or  the  other.  These  tumors  are 
formed  in  a  variety  of  ways.  Coils  of  intestine  may  become  adherent 
and  form  a  mass  resembling  a  solid  abdominal  tumor ;  the  omentum 
may  become  thickened  and  curled  upon  itself;  mesenteric  glands, 
especially  in  children,  are  liable  to  be  the  seat  of  tubercular  enlarge- 
ment and  attain  considerable  size,  and  circumscribed  collections  of 
fluid  walled  in  by  strong  adhesions  constitute  the  last  class  of  these 
deceptive  tumors.  The  abdominal  wall  is  frequently  found  to  have 
more  than  a  normal  resistance,  due  to  a  thickening  of  the  peritoneum. 
Vaginal  or  rectal  examinations  will  also  demonstrate  a  thickening  of 
the  membrane. 

A  sign  of  great  importance  in  the  diagnosis  of  tubercular  peritonitis 
is  an  erythema  which  in  some  cases  surrounds  the  umbilicus.  This 
is  regarded  by  Dr.  Henry  ^  as  pathognomonic,  and  is  shown  in  Fig. 

Many  diseased  conditions  may  be  mistaken  for  tubercular  peritonitis. 
In  fact,  a  large  proportion  of  the  cases  which  have  been  operated  upon 
have  been  incorrectly  diagnosed.  The  errors  have  been  fortunate  ones, 
for  by  them  surgeons  have  stumbled  on  a  treatment  which  is  very  suc- 
cessful. In  1864,  Spencer  Wells,  operating  upon  what  he  supposed  to 
.  be  an  ovarian  tumor,  found  on  opening  the  abdomen  that  the  fluid  was 
free  in  the  peritoneum,  while  the  membrane  itself  was  studded  with 
miliary  tuberculosis.  The  patient  recovered,  and  was  free  from  disease 
twenty-six  years  afterward. 

Against  tubercular  peritonitis  the  following  must  be  carefully  differ- 
entiated : 

1.  Abdominal  tumors.  An  ovarian  cyst  has  many  points  in  com- 
mon. In  it,  however,  there  is  generally  a  freedom  from  pain,  tender- 
ness, and  fever  until  the  tumor  has  attained  to  a  larger  growth. 
Bimanual  examination  will  also  prove  of  value  in  the  majority  of 
cases.  Pyosalpinx  or  hydrosalpinx  has  its  characteristic  attacks 
of  localized  pain,  a  history  of  disordered  menstruation,  and  the  cha- 
racteristic tumor  felt  on  examination.  Pyonephrosis  and  hydronephro- 
sis have  their  renal  manifestations.  An  enlarged  gall-bladder  is  con- 
nected with  the  liver,  and  ascends  and  descends  with  respiration. 
Malignant  tumors  in  the  abdominal  cavity  are  usually  more  rapid 
in  their  progress  than  tubercular  peritonitis,  and  frequently  are  but 
extensions  of  the  disease  from  other  parts. 

2.  Ascites  of  non-tubercular  origin.  This  may  be  excluded  by 
taking  into  consideration  the  etiology  of  ascites.  The  condition  of 
the  liver,  the  existence  of  jaundice,  and  a  careful  examination  of  the 
urine  will  generally  settle  the  point. 

3.  Typhoid  fever.  Acute  tubercular  peritonitis  may  closely  simu- 
late typhoid  fever.  The  points  which  aid  in  differentiation  are — the 
absence  of  typhoid  spots,  the  less  constant  diarrhea,  the  absence  of 
the  typical  remissions  of  temperature,  and  the  non-limitation  of  the 
point  of  tenderness  to  the  cecal  region. 

In  spite  of  every  precaution  the  case  may  puzzle  the  most  expe- 

1  htternational  Clinics,  vol.  iv.  5th  series.  • 


288  SLKG/CAI.    lUAGXOS/S  AND    TREATMENT. 

riciiccd,  and  the  real  state  of  matters  be  only  found  after  oi)enin<j  the 
abdomen. 

Trcatnioit. — Wh)'  it  should  be  so  no  one  has  yet  been  able  clearly 
to  explain,  but  experience  has  shown  that  celiotomy  with  drainage  has 
not  onl\-  given  immediate  relief  in  tubercular  peritonitis,  but  in  many 
cases  has  effected  a  permanent  cure.  This  is  more  particularly  the  case 
when  the  ascites  is  circumscribed.  The  incision  is  made  in  the  middle 
line  midway  between  the  umbilicus  and  pubis,  except  where  localized 
collections  of  fluid  demand  special  incisions.  Care  must  be  taken  to 
avoid  wounding  the  intestine,  as  there  is  a  likelihood  of  its  being 
adherent  to  the  abdominal  wall  at  the  point  operated  on.  The  peri- 
toneum should  be  carefully  sought  and  divided,  the  bowel  separated 
if  adherent.  Caseous  matter  should  be  scraped  away  with  a  sharp 
spoon  and  iodoform  thoroughly  rubbed  into  the  raw  surfaces.  After 
allowing  the  fluid  to  escape  and  washing  the  cavity  with  Thiersch's 
solution  or  a  very  weak  solution  of  iodin,  a  glass  drainage-tube  is 
inserted,  around  which  is  packed  strips  of  iodoform  gauze.  Some 
operators  dust  iodoform  over  the  whole  peritoneal  surface.  The 
drainage-tube  must  not  be  removed  as  long  as  there  is  any  fluid 
escaping,  a  process  which  may  continue  for  weeks  or  even  months. 

Carcinoma  of  the  peritoneum  is  rarely  primary  in  its  origin. 
It  is  quite  common,  however,  for  malignant  disease  to  spread  from  one 
of  the  abdominal  organs  to  the  peritoneum  covering  that  organ,  and 
thence  to  various  parts  of  the  serous  membrane.  The  peritoneum 
covering  the  stomach,  the  large  intestine,  and  especially  the  cecum,  are 
the  most  common  seats  of  the  disease.  Less  frequently  it  is  found  in 
the  membrane  covering  ovaries,  the  kidneys,  the  liver  and  gall-bladder, 
the  pancreas,  and  the  suprarenal  capsules.  After  its  extension  to  the 
peritoneum  cancer  seems  to  show  a  preference  for  the  omentum,  and 
masses  of  malignant  growth  are  sometimes  found  in  it  which  weigh  as 
much  as  ten  or  twelve  pounds.  The  peritoneum  in  Douglas's  pouch 
and  that  near  the  umbilicus  are  also  common  seats  of  the  disease. 
The  presence  of  carcinoma  leads  to  inflammation  of  the  peritoneum  ; 
consequently  an  exudation  of  plastic  material  or  an  effusion  of  fluid  is 
commonly  associated  with  peritoneal  cancer.  The  liquid  exudation  is 
frequently  hemorrhagic,  and  the  ascites  of  a  milky  character  due  to  the 
breaking  down  of  cancerous  tissue  by  fatty  degeneration  (Fitz). 

Symptoms. — Since  many  of  the  cases  of  peritoneal  cancer  have  been 
discovered  only  after  death,  it  is  evident  that  there  are  no  very  definite 
symptoms  by  which  the  disease  can  be  recognized.  The  primary 
organic  cancer,  as  a  rule,  overshadows  the  peritoneal  complication,  and 
by  the  time  the  peritoneum  becomes  involved  the  case  is  usually  beyond 
hope.  Generally  speaking,  the  symptoms  indicating  cancer  of  the  peri- 
toneum are  peritonitis  and  ascites.  Pressure  upon  the  intestine  pro- 
duces constipation,  and  possibly  meteorism,  A  considerable  collection 
of  fluid  causes  dyspnea  and  disturbances  of  the  circulation.  There  is 
generally  fever,  very  similar  in  character  to  that  observed  in  tubercular 
peritonitis.  After  the  disease  has  far  advanced  the  cancerous  pallor  and 
cachexia  become  apparent. 

Two  serious  complications  are  likely  to  arise  in  the  course  of  the 
disease.     One  is  hemorrhage,  due  to  erosion  of  vessels  in  the  cancer- 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE  SYSTEM.       289 

ous  mass ;  the  other  is  perforation  of  the  bowel,  due  to  the  cancerous 
process  destroying  the  wall  of  an  affected  portion  of  the  intestine.  In 
the  one  case  we  would  have  a  sudden  onset  of  symptoms  which  point 
to  hemorrhage,  and  in  the  other  the  sudden  pain  and  peritonitis  which 
follow  perforation. 

In  view  of  the  fact  that  the  pelvic  peritoneum  is  so  frequently  the 
seat  of  cancer  a  vaginal  or  rectal  examination  should  never  be  neglected 
in  any  suspicious  case. 

Sarcoma  of  the  Omentum. — When  a  malignant  tumor  has  its 
primary  seat  in  the  omentum,  it  is  always  a  sarcoma,  as  carcinoma  does 
not  occur  here.  When  the  tumor  has  reached  a  considerable  size,  it  is 
readily  recognized,  for  it  lies  just  within  the  abdominal  wall,  and  has  a 
feeling  which  has  been  compared  to  the  back  of  a  turtle.  This  turtle- 
like tumor  is  freely  movable,  and  remains  free  from  adhesions  until  an 
advanced  stage  of  the  disease.  Early  recognition  of  the  tumor  is  of 
great  importance,  for  at  this  period  it  is  free  from  complications,  and  if 
removed  the  prospects  are  favorable.  The  operation  of  removal  con- 
sists in  making  a  free  abdominal  incision,  drawing  down  the  omentum, 
and  by  multiple  ligatures  tying  it  off  at  a  safe  distance  from  the  tumor. 

Benign  tumors  of  the  peritoneum  are  found  between  the  folds 
of  the  membrane ;  that  is,  in  the  mesentery  and  omentum.  They  are 
lipomata,  fibromata,  myxomata,  hemangiomata,  chylangiomata,  and 
serous  cysts.  Rarely  are  benign  tumors  found  to  arise  from  the  free 
surface  of  the  peritoneum.  The  diagnosis  of  these  is  generally  difficult 
and  uncertain.  Given  a  tumor  lying  deeply  in  the  abdominal  cavity, 
the  closest  scrutiny  should  be  made  to  ascertain  whether  any  organ  or 
any  part  of  the  intestine  has  been  involved.  The  kidney  can  be 
excluded  by  changes  in  the  character  or  amount  of  the  urine ;  the 
intestine,  by  the  presence  of  diarrhea  or  obstruction ;  and  the  stomach, 
by  evidence  of  constriction  or  vomiting.  If  in  this  manner  all  the 
organs  can  be  excluded,  it  is  reasonable  to  infer  that  the  tumor  is  in 
the  mesentery.  The  most  common  cause  of  error  in  the  case  of  cysts 
is  their  resemblance  to  ovarian  tumors.  From  these  they  must  be 
differentiated  by  the  train  of  symptoms  which  characterize  cysts  of  the 
ovaries. 

Treatment. — A  patient  was  presented  to  the  Paris  Academy  of 
Medicine  from  whom  Terrillon  removed  a  fatty  tumor  weighing  fifty- 
seven  pounds,  and  which  lay  between  the  folds  of  the  mesentery.  Sir 
Spencer  Wells,  Romans  of  Boston,  Brookhouse  of  Nottingham,  and 
others  have  reported  cases  of  a  similar  nature. 

Rupture  of  the  peritoneum  is  a  rare  accident.  The  most 
common  situation  is  in  the  peritoneum  covering  the  uterus.  The  mem- 
brane over  the  stomach,  intestine,  the  mesentery,  and  omentum  has 
also  been  ruptured  by  blows  or  by  over-distention.  The  dangers  of  such 
a  lesion  are  two  in  number — viz.  peritonitis  and  hemorrhage.  Diag- 
nosis must  rest  upon  the  symptoms  of  these  as  already  described. 

Wounds  of  the  Peritoneum. — The  peritoneum  was  long  mis- 
understood. Until  recent  years  a  wound  of  this  membrane  was  looked 
upon  with  horror,  and  the  surgeon  who  fearlessly  amputated  limbs, 
removed  tumors,  and  ligated  arteries  stood  aghast  when  he  reached 
the  peritoneum,  as  if  Dante  had  written  upon  that  delicate  parchment, 

19 


290  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

"  Abandon  hope,  all  ye  who  enter  here."  When  no  note  was  taken  of 
septic  ^erm.s,  and  the  abdominal  cavity  was  entered  with  unclean  hands, 
^erni-laden  sponges,  and  unsterilized  instruments,  peritonitis  and  death 
followed  as  an  almost  universal  rule. 

Aseptic  surgery  has  demonstrated  the  true  position  of  the  peritoneum. 
It  is  a  membrane  of  great  absorbing  power.  It  can  be  incised  with 
perfect  safety,  provided  the  wound  is  kept  aseptic.  It  has  a  greater 
power  to  resist  disease-germs  than  have  most  of  the  other  tissues.  A 
wound  of  the  peritoneum  heals  readily,  provided  the  surfaces  be  kept  in 
apposition.  Firm  adhesions  take  place  between  the  serous  surfaces 
even  in  a  few  hours,  and  the  healing  process  is  complete  in  a  week  or 
ten  days.  In  treating  a  wound  of  this  membrane  the  cut  edges  should 
be  brought  together  by  sutures. 

Serous  surfaces  readily  unite  to  serous  surfaces,  and  the  discovery 
of  this  fact  lies  at  the  bottom  of  all  the  methods  for  closing  intestinal 
wounds  or  making  anastomoses.  Union  is  made  more  certain  if  the 
serous  surfaces  are  first  scarified  and  then  approximated.  An  opening 
in  the  peritoneum  should  always  be  closed  in  order  to  prevent  adhe- 
sions of  the  membrane  to  internal  organs  and  to  guard  against  ventral 
hernia.  A  slit  in  the  mesentery  should  be  carefully  closed,  lest  a  loop 
of  intestine  slip  through  the  opening  and  become  strangulated. 

VIII.   INJURIES  AND   DISEASES  OF  THE   LIVER. 

Before  considering  the  diseased  or  injured  liver  let  us  briefly  review 
a  few  anatomical  points  in  the  normal  condition  of  the  organ. 

The  lower  border  of  the  fourth  rib  on  the  right  side  corresponds 
to  the  upper  border  of  the  liver.  The  highest  point  is  at  the  junction 
of  the  fourth  rib  with  its  cartilage.  On  the  left  side  the  junction  of  the 
sixth  rib  with  its  cartilage  corresponds  with  the  upper  portion  of  the 
left  lobe.  The  lower  border  of  the  liver  follows  the  lower  limit  of  the 
ribs  posteriorly  and  as  far  forward  as  the  cartilage  of  the  tenth  rib. 
From  this  point  it  runs  toward  the  junction  of  the  fifth  left  rib  with  its 
cartilage.  While  these  points  indicate  the  normal  position,  percussion 
will  not  always  verify  them.  The  lung  may  overlap  the  liver  from 
above,  giving  resonant  sounds,  and  the  distended  intestines  below  may 
limit  the  dulness  in  that  direction. 

The  lower  border  may  be  felt  by  the  palpating  fingers,  and  a  notch 
in  its  sharp  edges  detected  near  the  middle  line.  It  corresponds 
with  the  attachment  of  the  broad  ligament,  and  from  this  point  to  the 
umbilicus  runs  the  suspensory  ligament  composed  of  two  layers  of 
peritoneum.  In  this  fold  is  contained  the  obliterated  umbilical  vein. 
Should  the  vein  happen  to  be  not  totally  obliterated,  an  incision  in  this 
region  might  result  in  serious  hemorrhage. 

An  important  feature  in  diagnosis  about  the  liver  is  that  the  organ 
rises  and  falls  to  a  certain  extent  with  the  movements  of  respiration, 
carrying  the  gall-bladder  with  it.  This  movement  is  useful  in  differ- 
entiating an  enlarged  gall-bladder  from  other  tumors  in  the  abdomen . 

The  liver-substance  is  vascular  and  bleeds  freely  when  incised.  It  is 
also  brittle  and  easily  torn,  but  in  either  case  the  hemorrhage  is  a 
sluggish  oozing  which  can  be  readily  stopped  by  pressure  or  sutures. 


INJURIES  AND   DISEASES   OF   THE   DIGESTIVE   SYSTEM.        29 1 

Bxamination  of  the  I/iver. — On  palpation  the  liver  in  thin  per- 
sons may  be  felt  below  the  border  of  the  ribs  and  in  the  epigastrium. 
In  passing  the  finger  over  the  organ  we  note  any  enlargement  by  the 
extent  to  which  it  is  pressed  downward  into  the  abdomen.  The  fingers 
can  detect  any  nodules  indicative  of  carcinoma  or  the  bogginess  sug- 
gestive of  abscess  or  the  hepatic  fremitus  which  attends  hydatids  or 
perihepatitis.  It  is  rarely  that  we  can  feel  the  gall-bladder,  but  when 
over-distended  or  enlarged  by  the  pressure  of  calculi  it  can  occasionally 
be  felt  without  difficulty. 

Percussion. — It  must  be  remembered  that  when  the  patient  lies 
down  the  liver  rotates  upon  its  transverse  axis.  This  causes  the  ante- 
rior margin  to  slip  up  under  the  ribs,  so  that  the  area  of  dulness  is  not 
the  same  as  when  the  patient  is  standing.  The  upper  limit  is  always 
covered  with  lung,  and  cannot  be  accurately  defined  by  percussion. 
In  the  normal  liver  absolute  dulness  along  the  upper  border  should 
occur  as  follows : 

Posteriorly,  the  tenth  rib. 
In  the  axillary  line,  the  eighth  rib. 

In  the  mammillary  line,  the  lower  border  of  the  si.xth  rib. 
In  the  parasternal,  just  above  the  sixth  rib. 
In  the  mid-sternal,  the  base  of  the  ensiform  cartilage. 
Beginning  posteriorly,  it  may  help  the  memory  to  recall  the  number 
1086.  ^ 

The  lower  border  cannot  be  found  posteriorly,  owing  to  the  thick- 
ness of  the  lumbar  muscles. 

The  other  limits  are  as  follows : 

In  the  a.xillary  line,  between  the  tenth  and  eleventh  ribs. 
In  the  mammillary  line,  the  free  margin  of  the  ribs. 
In  the  mid-sternal,  midway  between  the  base  of  the  ensiform  carti- 
lage and  the  umbilicus. 

Rupture  of  the  I/iver. — The  liver  is  apt  to  be  ruptured  by 
crushing  forces,  such  as  the  passage  over  the  body  of  heavy  wagons. 
It  may  also  be  ruptured  by  the  ends  of  broken  ribs  or  by  the  abdomen 
being  jumped  upon.  In  some  cases  the  organ  has  been  completely 
broken  through  ;  in  some  it  has  been  ruptured  at  its  lower  or  upper 
border ;  in  others  a  portion  has  been  broken  off  and  found  lying  loose 
in  the  abdomen. 

The  syniptovis  of  rupture  of  the  liver  are  summed  up  in  two  words 
— internal  hemorrhage  and  shock.  The  immediate  result  of  rupture  is 
copious  hemorrhage ;  this  is  recognized  by  extreme  pallor  and  cold- 
ness of  the  skin  ;  the  pulse  is  small  and  feeble ;  the  respiration  short 
and  sighing ;  the  abdomen  becomes  swollen  and  tympanitic  ;  possibly 
dulness  at  the  most  dependent  parts  will  show  where  the  blood  is 
collecting.  There  is  often  vomiting,  thirst,  and  syncope.  When  the 
patient  survives  the  first  twenty-four  hours  jaundice  is  likely  to  set  in. 
When  death  does  not  take  place  directly  from  the  shock  and  hemor- 
rhage, peritonitis  is  sure  to  follow,  with  abscess  of  the  liver  or  adjoining 
parts. 

The  treatment  must  be  expectant. 

Wounds  of  the  I/iver. — Wounds  of  the  parenchyma  made 
during  the  course  of  operations  bleed  freely,  but  packing  with  sponges 


292  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

or  gauze  for  a  few  iiiimitcs  readily  controls  the  flow,  and  a  row  of  cat- 
gut sutures  permanently  closes  the  bleeding  vessels.  Accidental 
wounds  are  not  common.  The  .symptoms  of  penetrating  wounds  arc 
hemorrhage  and,  in  some  cases,  a  discharge  of  bile.  A  pain  in  the  right 
shoulder  is  indicative  of  an  injury  to  the  liver,  and  may  accompany  a 
wound  of  the  viscus.  If  the  upper  surface  be  wounded,  the  pain  is  felt 
at  the  larynx  and  shoulder ;  if  the  under  surface,  the  pain  is  felt  at  the 
ensiform  cartilage.  Vomiting,  hiccough,  dyspnea,  and  delirium  are 
also  s)'mptoms.  Common  sense  must  be  employed  to  determine  the 
direction  taken  by  the  penetrating  instrument.  If  it  enters  the  lower 
intercostal  spaces  and  goes  through  the  thoracic  wall,  the  liver  must 
suffer;  if  it  enter  below  the  ribs  and  take  a  direction  upward,  the 
result  is  the  same.  If  it  enter  the  chest  above  the.  points  already 
mentioned  as  forming  the  upper  border  of  the  liver,  then  the  lung  is  the 
organ  to  suffer,  and  we  must  look  for  pulmonary  symptoms. 

Treatment. — If  bile  and  blood  escape  from  the  external  wound,  the 
latter  should  not  be  closed,  but  be  kept  open  and  gently  packed  with 
iodoform  gauze.  If,  however,  it  is  evident  that  this  is  insufficient,  the 
abdomen  should  be  opened  and  the  wound  in  the  liver  closed  by 
sutures. 

Abscess  of  the  I^iver. — Although  it  has  been  customary  in  text- 
books to  describe  this  disease  as  if  it  were  confined  to  tropical  climates, 
I  am  convinced  that  it  is  much  more  frequently  met  with  in  the  tem- 
perate zone  than  is  generally  supposed.  It  presents  a  great  variety  of 
phases,  and  no  definite  typical  symptoms  can  be  laid  down  for  its 
diagnosis.  In  1881,  I  operated  on  a  child  eight  months  old,  and  evac- 
uated about  six  ounces  of  pus  mixed  with  bile,  after  which  a  rapid 
recovery  took  place.  In  this  case  the  symptoms  were  fever,  with 
a  bulging  and  fluctuation  in  the  right  mammillary  line  over  the  liver.  In 
the  case  of  a  boy  aged  fifteen  symptoms  resembling  typhoid  fever, 
which  disease  was  then  prevalent,  continued  for  three  weeks,  when  a 
large  quantity  of  pus  was  discharged  into  a  bronchial  tube  and  expelled 
by  coughing.  This  was  followed  by  rapid  improvement  for  about  two 
weeks,  when  a  relapse  occurred.  After  collecting  again,  the  abscess 
found  its  way  into  the  intestine,  and  a  large  quantity  of  pus  was  dis- 
charged per  rectum.  This  did  not  end  the  matter.  A  recurrence  of 
the  same  symptoms  was  followed  by  a  third  and  last  escape  of  pus. 
This  time  it  was  voided  with  the  urine,  the  abscess  having  no  doubt 
discharged  into  the  ureter. 

Causes. — Wounds  and  contusions  may  end  in  abscess  of  the  liver, 
provided  septic  germs  find  an  entrance  to  the  tissues  at  the  time  of  or 
subsequent  to  the  traumatism.  Besides  this  direct  infection,  pyogenic 
or  other  germs  may  find  a  portal  of  entrance  by  the  bile-  or  blood- 
channels.  In  this  manner  the  inflammatory  and  ulcerative  processes 
which  attend  dysentery,  appendicitis,  hemorrhoids,  and  uterine  phlebitis 
may  be  the  precursors  of  hepatic  abscess.  A  very  important  point  for 
the  surgeon  to  remember  is  that  operations  for  hemorrhoids,  fistula  in 
ano,  or  prolapsus  of  the  rectum  have  been  followed  by  abscess  of  the 
liver.  Embolism  of  the  hepatic  artery,  gall-stones,  parasites,  and 
foreign  bodies  in  the  bile-ducts,  such  as  pins,  needles,  or  nails,  may  also 
be  set  down  as  causes. 


INJURIES    AND   DISEASES   OF   THE   DIGESTIVE   SYSTEM.  293 

Syinptoms. — A  small  abscess  may  produce  no  special  symptoms,  and 
even  a  large  collection  of  pus  may  take  place,  and  be  recognized  for  the 
first  time  in  the  post-mortem  room  or  when  evacuated  by  some  other 
channel,  as  the  bronchi  or  intestine. 

A  small  abscess  near  the  surface  is  attended  with  severe  pain,  high 
fever,  and  rapid  pulse,  while  a  deep-seated  abscess,  even  if  large,  may 
produce  only  slight  disturbance.  The  general  effect  of  an  hepatic 
abscess  is  to  produce  in  the  patient  a  progressive  wasting  of  flesh  and 
failure  of  strength,  with  loss  of  appetite,  nausea,  vomiting,  and  a  feeling 
of  weight  at  the  epigastrium.  If  the  upper  surface  of  the  liver  is 
inflamed,  the  pleura  and  base  of  the  lung  may  participate,  causing 
cough  and  hectic  fever  and  leading  to  an  erroneous  diagnosis  of  pul- 
monary phthisis.  It  would  be  natural  to  expect  that  jaundice  would 
be  a  prominent  symptom,  but  experience  proves  that  it  is  rare,  and  in 
fact  its  presence  argues  against  rather  than  for  hepatic  abscess.  In 
forming  an  opinion  we  must  weigh  well  the  following  symptoms  : 

{a)  Temperature.  Although  the  disease  may  exist  with  little  or  no 
fever,  the  rule  is  that  there  is  a  well-marked  rise  of  temperature,  often 
reaching  104°  or  105°  F.  When  this  is  attended  with  chills  the  sus- 
picion of  suppuration  is  strong.  Sometimes  the  chill  is  followed  by 
sweats  and  a  sudden  fall  of  temperature,  and  there  is  a  danger  of  mis- 
taking the  disease  for  malaria.  But  this  can  be  excluded  by  remem- 
bering that  the  chills  do  not  come  at  regular  periods,  as  they  do  in 
intermittent  fever.  Sometimes  the  temperature  follows  a  steady  course 
with  a  slight  evening  increase,  as  happens  in  typhoid  fever.  Then  we 
must  look  for  typhoid  spots,  enlarged  spleen,  and  other  symptoms  of 
enteric  fever. 

{li)  Local  evidence  of  the  presence  of  pus.  Palpation  will  generally 
prove  that  the  whole  liver  is  enlarged.  The  lower  border  can  be  felt 
under  the  ribs,  and  pressure  there  produces  pain.  Carcinoma  of  the 
liver  can  generally  be  distinguished  by  feeling  the  hard  nodules  of  that 
disease.  In  the  advanced  stages  fluctuation  can  perhaps  be  felt  and  a 
swelling  observed  in  the  abdominal  wall.  We  are  not  usually  so  for- 
tunate as  to  have  the  case  so  clear.  If,  however,  we  have  tenderness 
and  enlargement  of  the  liver,  with  some  of  the  other  symptoms  already 
mentioned,  we  should  proceed  to  use  the  exploring  needle.  Although 
exploratory  puncture  is  not  to  be  recommended  in  the  examination  of 
the  abdomen  generally,  this  condition  must  be  considered  an  exception, 
for  if  the  liver  be  enlarged  and  bulging  against  the  abdominal  wall, 
there  is  little  danger  of  the  escape  of  pus  into  the  peritoneal  cavity. 
The  skin  and  needle  should  of  course  be  well  disinfected.  It  is  better 
to  use  the  exploring  needle  than  wait  for  the  abscess  to  burst  into  the 
bowel  or  bronchus.  When  it  opens  into  the  intestine,  a  copious  liquid 
evacuation  containing  pus  reveals  the  fact,  while  a  free  expectoration 
of  chocolate-colored  material  announces  that  the  abscess  has  ruptured 
into  a  bronchial  tube.  In  rare  cases  the  kidney  or  ureter  is  ulcerated 
into,  and  the  pus  evacuated  by  the  urethra,  or  it  may  rupture  into  the 
pleural  or  peritoneal  cavity,  the  pericardium,  or  externally  through  the 
abdominal  wall.  There  is  a  peculiar  muddy  countenance  which  is 
indicative  of  hepatic  abscess. 

Diagnosis. — The  disease  most  closely  resembling  hepatic  abscess  is 


294  SCMGICAL    DIAGNOSIS  AND    TREATMENT. 

perihepatitis.  This  is  an  inflammation  of  the  capsule  of  the  hver,  and 
may  occur  as  a  primary  disease  or  be  simply  an  extension  of  inflamma- 
tion from  the  liver  to  its  cajjsule.  It  is  often  the  result  of  abscess  of 
the  lixer.  While  perihepatitis  causes  pain,  tenderness,  and  fever,  it  is 
a  disease  of  short  duration  (several  days),  while  abscess  is  slow  in  its 
development  and  may  be  a  disease  of  months.  Hydatid  cysts  have  led 
to  errors  in  diagnosis.  In  the  case  of  uncomplicated  hydatids  there  is 
no  pain  or  fever.  Hydatid  cysts,  however,  may  suppurate,  and  then 
the  symptoms  are  practically  those  of  liver-abscess.  The  so-called 
hydatid  fremitus  is  of  very  little  value  in  aiding  the  diagnosis. 

To  sum  up :  Abscess  of  the  liver  is  recognized  by  wasting  and  loss 
of  strength,  a  muddy  complexion,  enlargement,  pain  and  tenderness  of 
the  organ,  bulging  and  fluctuation  in  rare  instances,  and  the  discovery 
of  pus  by  the  exploring  needle. 

Can  we  determine  the  portion  of  the  liver  which  is  the  seat  of 
abscess  ?  Sometimes  we  can.  If  cough  and  dyspnea  are  present  in 
addition  to  the  general  symptoms,  the  abscess  is  at  the  upper  surface. 
If  vomiting  and  nausea  are  prominent,  the  lower  surface  is  the  seat  of  the 
abscess.  If  situated  in  the  posterior  portion  of  the  right  lobe,  there 
may  be  bulging  and  bogginess  posteriorly  near  the  spine.  A  super- 
ficial abscess  produces  acute  symptoms ;  a  deep  abscess  is  slow  in 
progress,  and  its  symptoms  are  indefinite. 

Treatment. — Following  the  broad  principle  that  wherever  pus  exists 
it  should  be  evacuated  and  drained,  there  should  be  only  one  opinion 
regarding  treatment  of  abscess  of  the  liver.  There  are  several 
methods  by  which  hepatic  abscess  can  be  treated ;  they  are  briefly  as 
follows : 

1.  Aspiration.  This  is  more  valuable  as  a  diagnostic  than  as  a  cura- 
tive procedure.  A  good-sized  needle  should  be  employed,  and  after 
careful  disinfection  it  should  be  filled  with  a  solution  of  carbolic  acid 
(i  :  20).  The  skin  should  not  only  be  sterilized,  but  a  small  opening 
should  be  made  with  a  knife  through  the  outer  skin.  This  disposes  of 
the  epithelium  and  everts  the  danger  of  carrying  any  germs  into  the 
interior.  Repeated  aspirations  have  been  recommended,  but  with  the 
discovery  of  pus  the  usefulness  of  the  aspirating  needle  may  be  said  to 
end.  It  can  be  left  in  position  as  a  guide  for  the  incision.  Care  should 
be  taken  to  allow  the  needle  to  move  with  the  liver  as  it  rises  and  falls 
during  respiration.  If  held  too  firmly  the  instrument  is  liable  to  tear 
the  liver  substance,  which  is  always  pliable  and  easily  lacerated. 

2.  Puncture  by  trocar.  In  this  method  a  large-sized  trocar  is  intro- 
duced and  withdrawn,  leaving  the  cannula  in  position.  Through  the 
cannula  the  pus  escapes  and  frequent  washings  of  the  cavity  are 
effected.  The  objection  to  this  method  is  that  it  does  not  give  free 
enough  drainage  and  prolongs  the  suppurative  process. 

3.  Free  incision  and  drainage.  This  is  the  only  thorough  and  trust- 
worthy method  of  dealing  with  the  abscess.  If  we  have  positive  assur- 
ance that  firm  adhesions  exist  between  the  liver  and  the  abdominal  wall, 
a  dissection  through  the  tissues  one  by  one  until  the  abscess  is  reached 
is  all  that  is  required.  The  cavity  is  then  well  washed  out,  and  packed 
with  iodoform  gauze  or  drained  by  rubber  tubes. 

Rarely  can  we  have  the  assurance  that  adhesions  exist.    The  opera- 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE  SYSTEM.        295 

tion  which  will  meet  every  demand  is  one  usually  designated  hepatotomy, 
and  is  performed  as  follows  : 

1.  Over  the  most  prominent  part  of  the  tumor,  or  at  the  point  where 
the  exploring  needle  has  demonstrated  the  presence  of  an  abscess,  an 
incision  is  made  through  the  abdominal  wall,  as  in  an  ordinary  celi- 
otomy. Both  the  longitudinal  and  the  transverse  incisions  have  their 
advocates.     The  opening  should  be  four  or  five  inches  in  length. 

2.  Examine  the  surface  of  the  liver,  and  if  at  any  part  adhesions  are 
found,  open  into  the  liver  at  that  point,  even  if  it  does  not  correspond 
to  the  abdominal  opening.  If  there  are  no  adhesions,  the  opening  is 
made  directly  into  the  liver  in  the  following  manner :  Pack  several  flat 
sponges  or  gauze  pads  around  the  spot  to  be  opened  on  the  liver,  so  as 
to  catch  any  pus  that  may  escape  and  prevent  its  getting  into  the  peri- 
toneal cavity.  If  not  yet  satisfied  of  the  existence  of  an  abscess,  pass 
a  large  exploring  needle  into  the  liver,  and,  using  the  needle  as  a  guide, 
make  an  incision  large  enough  to  admit  the  fore  finger.  The  finger  is 
then  used  as  a  hook  to  draw  the  liver  up  against  the  abdominal  wound, 
while  an  assistant  presses  upon  the  walls  and  keeps  them  in  close  appo- 
sition to  the  liver.  Having  thus  guarded  against  the  escape  of  pus  into 
the  peritoneum,  the  blade  of  a  long,  slender  knife  is  passed  along  the 
finger  and  the  opening  enlarged  to  the  required  extent.  The  edges  of 
the  opening  in  the  liver  are  now  caught  in  the  blades  of  several  pairs 
of  forceps  and  kept  well  up  into  the  abdominal  wound,  while  the 
abscess-cavity  is  being  thoroughly  irrigated.  The  finger  is  again  in- 
serted and  made  to  sweep  around  the  cavity  in  search  of  secondary 
abscesses,  which,  if  present,  can  be  torn  open  by  the  finger  or  by 
forceps,  and  the  irrigation  continued  or  the  pus  mopped  out  with 
soft  sponges. 

3.  The  cavity  being  now  empty  and  wiped  clean,  and  any  fluid  that 
escaped  into  the  peritoneal  cavity  wiped  up,  the  edges  of  the  liver- 
wound  are  stitched  to  the  opening  in  the  abdominal  wall.  The  soft 
sponge  is  used  to  plug  the  abscess-cavity,  the  sponges  packed  around 
the  opening  are  removed,  and  with  a  continuous  suture  of  stout  catgut 
the  lips  of  the  wound  in  the  liver  are  secured  to  the  abdominal  wall. 
The  sponge  is  removed  from  the  abscess-cavity,  and  a  drainage-tube  or 
strips  of  iodoform  gauze  inserted,  to  be  changed  as  often  as  the  dis- 
charge shall  demand.  A  copious  antiseptic  dressing  completes  the 
operation. 

4.  Incision  in  two  stages.  To  ensure  greater  safety,  and  particularly 
to  guard  against  the  risk  of  infecting  the  peritoneal  cavity,  the  opera- 
tion can  be  done  in  two  stages.  As  a  rule,  the  case  is  too  urgent  to 
admit  of  the  necessary  delay.  In  the  first  stage  the  abdominal  open- 
ing is  made  down  to,  but  not  through,  the  peritoneum,  and  into  this 
wound  a  packing  of  sterilized  gauze  is  placed,  a  dressing  applied,  and 
the  patient  sent  back  to  bed.  At  the  end  of  forty-eight  or  seventy-two 
hours  the  operation  is  completed  by  making  the  incision  into  the  liver. 
Firm  adhesions  have  had  time  to  take  place  and  the  peritoneal  cavity 
is  saved. 

Barwell  recommends  opening  the  peritoneum  at  the  first  opera- 
tion, lest  omentum  or  intestine  should  happen  to  lie  beneath  and  be 
incised  when  the  opening  is  made  into  the  liver. 


29<J 


SURGICAL    JUA GNOSIS  AND    TREATMENT. 


5.  Opening  b}'  caustics  or  the  thcrmo-cautery  is  fallin<j  into  disuse, 
and  it  is  not  likely  that  so  antiquated  and  barbarous  a  procedure  will 
be  rexivcd. 

Hydatids  of  the  I/iver. — In  the  intestine  of  the  dog,  the  wolf, 
and  other  animals  abounds  the  echinococcus  which  is  the  cestode  or 
larval  stai^e  of  the  tape- worm.  Human  beings  living  in  too  close  com- 
panionship with  dogs  are  liable  to  swallow  the  eggs  of  these  parasites. 
In  the  north-western  portions  of  Canada  and  the  United  States  Ice- 
landers form  the  majority  of  the  people  thus  affected.  The  eggs,  once 
in  the  alimentary  canal,  are  capable  of  passing  through  the  intestinal  wall 
into  the  liver.  Here  the  embryo  becomes  a  cyst  and  may  grow  to  an 
enormous  size.  In  the  liver  the  unilocular  variety  of  echinococcus  is 
most  frequently  met  with.  It  may  occupy  either  lobe  of  the  liver,  but 
is  most  frequent  in  the  right.  When  situated  near  the  surface  it  usually 
forms  a  well-marked  rounded  tumor,  easily  palpated  and  fluctuating. 
When  deeply  situated  in  the  hepatic  substance  it  causes  a  more  diffuse 
swelling,  with  the  liver-tissues  expanded  over  it.     As  the  tumor  grows 


Fig.  132. — Tumor  and  area  of  dulness  Fig.  133. — Tumor  and  area  of  dulness  in 

in  hydatids  of  the  liver  (side  view).  hydatids  of  the  liver  (front  view). 

(From  photographs  in  the  collection  of  Dr.  Strickler,  New  Ulm,  Minn.) 


pressure-symptoms  are  likely  to  appear.  If  the  upper  surface  be  the 
seat  of  the  cyst,  the  diaphragm  is  pressed  upward,  causing  dyspnea  and 
cough.  When  the  pressure  is  downward  the  bile-ducts  may  suffer 
pressure  and  jaundice  is  the  result. 

Symptoms. — In  the  liver  the  single  echinococcus  is  the  rule,  and  we 


I.\'JUR!ES  AND   DISEASES   OF  THE  DIGESTIVE   SYSTEM.       297 

have  to  deal  with  a  slowly-growing  cystic  tumor  free  from  inflammation 
and  producing  only  such  symptoms  as  are  due  to  growth  and  pressure 
(Figs.  132,  133).  It  sometimes  happens,  however,  that  the  cyst  suppu- 
rates, and  then  there  is  a  condition  closely  resembling  abscess  of  the 
liver.  A  small  cyst  is  devoid  of  any  symptoms  which  are  character- 
istic. The  first  symptom  to  attract  attention  is  usually  a  painless, 
slowly-growing  tumor  in  the  epigastrium  or  right  hypochondrium. 
Fluctuation  can  usually  be  detected.  The  tendency  of  the  growth  is 
downward,  and  as  it  comes  into  the  region  of  the  kidney  it  is  liable  to 
be  mistaken  for  hydronephrosis.  It  may  appear  singular  that  any  great 
difficulty  should  exist  in  the  diagnosis  between  a  disease  in  the  liver 
and  in  the  kidney,  but  it  is  a  clinical  fact  that  some  of  the  most  difficult 
questions  in  surgery  arise  on  these  very  points.  Hydronephrosis  has 
usually  a  history  of  chronic  kidney  disease,  such  as  renal  calculus  or  a 
movable  kidney  whose  ureter  becomes  twisted.  As  the  hydatid  tumor 
descends  still  farther  it  is  apt  to  be  confounded  with  ovarian  cyst.  The 
resemblance  to  ovarian  cyst  is  increased  by  the  presence  of  fluctuation 
all  over  the  abdomen,  while  the  flanks  are  resonant  as  in  ovarian 
tum.ors.  Bimanual  examination  is  an  excellent  aid  in  the  determination 
of  ovarian  cyst,  but  if  the  tumor  should  happen  to  have  a  long  pedicle, 
we  are  at  a  loss.  The  exploring  needle  is  to  be  condemned  in  the 
diagnosis  of  ovarian  cysts.  In  view  of  all  these  discouraging  features 
our  main  reliance  must  be  placed  on  the  history  and  the  direction  in 
which  the  tumor  has  developed.  From  pleurisy  on  the  right  side 
hydatids  are  distinguished  by  the  absence  of  fever  and  the  physical 
signs  of  inflammation  of  the  pleura.  The  pain  felt  in  the  right  shoulder 
in  liver-affections  may  be  of  some  value.  Given  a  smooth,  painless 
fluctuating  tumor  making  its  first  appearance  in  the  epigastrium  or 
right  hypochondrium,  we  may  strongly  suspect  hydatids,  and  should 
seek  to  settle  the  question  by  the  exploring  needle.  The  fluid  of 
hydatid  cysts  is  different  from  any  other  fluid  in  the  body.  It  is  albu- 
minous, contains  a  large  quantity  of  chlorid  of  sodium,  and  has  a 
specific  gravity  below  1015.  Under  the  microscope  the  hooklets  on 
the  laminated  echinococcus  membrane  may  be  found,  and  then  there 
can  be  no  possible  room  for  doubt. 

Diagnosis  is  sometimes  settled  by  rupture  of  the  cyst  into  the  lung, 
as  shown  by  the  expectoration  of  the  fluid  containing  hooklets.  Some- 
times the  rupture  takes  place  into  the  intestine,  and  a  few  cases  have 
been  reported  in  which  the  opening  was  into  the  pericardium.  In  any 
case  rupture  is  always  attended  with  danger  and  may  prove  suddenly 
fatal. 

Treatment. — Simple  puncture  and  aspiration  have  been  long  employed 
in  the  treatment  of  hydatids  of  the  liver,  and  many  cures  have  resulted, 
but  the  method  has  many  drawbacks,  among  which  may  be  mentioned 
escape  of  hydatid  fluid  into  the  peritoneal  cavity  and  return  of  the 
tumor  from  failure  to  destroy  the  mother-cyst.  Injection  of  chemical 
substances  and  the  use  of  electrolysis  may  be  placed  in  the  same 
category. 

The  success  and  slight  danger  attending  hepatotomy  have  made  it 
the  favorite  method  of  treatment  with  most  of  the  leading  surgeons. 
The  operation  should  be  resorted  to  as  soon  as  a  diagnosis  of  a  hydatid 


298  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

cyst  can  be  confidently  arrived  at.  It  is  true  that  such  a  cyst  may  go 
on  for  years  without  producing  much  discomfort,  but  it  is  equally  true 
that  rupture  may  take  place  at  any  time  and  produce  fatal  results,  or 
suppuration  may  supervene  and  place  the  patient  in  a  critical  position. 
It  is  much  safer  to  operate  upon  a  small  than  a  large  tumor,  and  this 
should  have  its  influence  in  determining  an  early  operation.  The 
operation  can  be  performed  in  either  one  or  two  stages : 

Operation  in  One  Staj^e. — Make  an  incision  over  the  most  prominent 
part  of  the  tumor  and  divide  all  the  tissues  down  to  the  peritoneum. 
Next  make  an  opening  in  this  membrane  and  pack  the  space  around  it 
with  antiseptic  sponges.  The  tumor  is  then  opened  and  its  contents 
allowed  to  escape,  after  which  the  edges  of  the  sac  are  stitched  to  the 
abdominal  wound,  a  drainage-tube  inserted,  and  a  copious  dressing 
applied. 

Operation  in  tivo  stages  is  safer  than  the  preceding,  and  should 
be  chosen  except  under  special  circumstances  which  demand  the 
immediate  evacuation  of  the  cyst.  The  first  stage  consists  in  making 
an  incision  down  to  and  through  the  peritoneum.  Just  below  the 
lower  margin  of  the  ribs  is  a  favorite  position  for  this  incision  when  it 
corresponds  with  the  position  of  the  tumor.  Having  opened  the  peri- 
toneum, a  tampon  of  iodoform  gauze  is  placed  in  the  wound,  a  dressing 
applied,  and  the  patient  sent  back  to  bed  for  five  or  six  days.  At  the 
end  of  this  time  the  adhesions  between  the  peritoneum  and  tumor  are 
so  firm  that  the  cyst  can  be  opened  into  without  risk  of  infecting  the 
peritoneal  cavity.  The  second  stage  consists  in  opening  the  cyst, 
which  can  be  done  without  an  anesthetic.  The  cavity  is  thoroughly 
w-ashed  out  with  an  antiseptic  solution,  a  drainage-tube  inserted  as 
before,  and  a  dressing  applied. 

F'loatingf  I/iver. — This  is  a  rare  affection,  found,  like  floating  kid- 
ney, in  women  who  have  rapidly  borne  children  and  suffered  loss  of 
flesh.  The  diagnosis  must  rest  upon  the  presence  of  a  large  abdominal 
tumor  w^hich  moves  about  as  the  patient  changes  her  position.  The 
absence  of  the  normal  hepatic  dulness  and  the  existence  of  this 
movable  body  are  very  suggestive.  The  pressure  of  the  liver  upon  the 
aorta  causes  pulsations  to  be  transmitted  to  the  tumor  which  must  not 
be  mistaken  for  the  pulsations  of  an  aneurysm. 

The  only  treatment  to  be  considered  is  the  wearing  of  a  suitable 
belt. 

IX.   INJURIES  AND   DISEASES  OF  THE  GALL=BLADDER. 

Anatomy. — The  gall-bladder  is  lodged  on  the  under  surface  of  the 
right  lobe  of  the  liver.  Its  length  is  about  four  inches  and  its  breadth 
about  one  and  a  quarter  inches.  It  consists  of  a  fundus,  a  body,  and  a 
neck.  The  fundus  only  is  covered  with  peritoneum.  It  projects  just 
below  the  anterior  edge  of  the  liver  at  the  position  of  the  cartilage  of 
the  ninth  rib.  The  body  of  the  gall-bladder  lies  in  such  relation  to  the 
right  flexure  of  the  colon  that  the  intestine  at  this  point  is  bile-stained 
when  examined  post-mortem.  It  also  lies  over  the  pyloric  end  of  the 
stomach  and  the  first  portion  of  the  duodenum.  These  relations  help 
to  explain  the  frequency  with  which  vomiting  and  pain  in  the  stomach 
attend  attacks  of  hepatic  colic.     The  neck  curves  upon  itself  like  the 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE   SYSTEM.       299 

letter  S,  and  empties  into  the  cystic  duct  at  the  transverse  fissure  of  the 
Hver.  The  cystic  duct  at  its  juncture  with  the  hepatic  duct  forms  an 
acute  angle,  from  which  point  the  common  duct  is  continued  to  empty 
into  the  duodenum.  During  the  intervals  of  digestion  the  bile  naturally 
gravitates  into  the  fundus,  which  is  the  lowest  part  of  the  gall-bladder. 
Here,  too,  lodge  gall-stones,  which  are  the  source  of  so  much  suffering, 
and  the  removal  of  which  has  claimed  so  much  attention  of  late  years 
(see  Fig.   134). 


^  f 

Fig.  134. — Types  of  gall-stones  :  a  caused  complete  intestinal  obstruction  for  eight  days ; 
i  and  c  were  removed  from  the  gall-bladder,  and  show  points  of  attrition  ;  d,  solitary  stone 
removed  from  gall-bladder  ;  no  point  of  attrition  ;  e,  gall-stone  of  irregular  shape,  due  to  com- 
pression or  moulding  ;  f,  solitary  stone  from  common  duct  (from  a  photograph  in  the  collection 
of  Dr.  Jepson,  Sioux  City,  la.). 

The  bile,  in  common  with  the  blood  and  nervous  tissues,  contains 
cholesterin.  In  the  liver  this  highly  carbonaceous  substance  is  held  in 
solution  by  the  fatty  acids  so  long  as  the  bile  is  alkaline.  It  has  been 
demonstrated  that  the  presence  of  calcium  in  any  fluid  containing 
cholesterin  causes  precipitation  of  that  substance.  It  is  also  found  that 
when  any  of  the  organic  acids  occur  in  excess  in  the  solids  or  liquids 
of  the  body  they  cause  the  calcium  of  the  anatomical  elements  to  be 
liberated.  Precipitation  of  cholesterin  follows.  Concentration  of  the 
bile  and  stagnation  in  the  bile-ducts  favor  precipitation. 

Another  important  factor  in  the  formation  of  gall-stones  is  catarrhal 
inflammation,  which  extends  from  the  intestine  up  the  ducts,  and  in 
which  the  bacterium  coli  commune  is  an  active  agent.  The  mucus 
deposited  in  the  gall-bladder  forms  a  ready  nucleus  for  the  precipitation 
of  bile-crystals.  If  there  happen  to  be  some  small  particles  of  solid 
matter  to  serve  as  a  nucleus  around  which  the  precipitated  cholesterin 
can  collect,  a  concretion  is  formed  which  is  called  a  gall-stone. 

Gall-stones  may  be  divided  into  the  following  classes : 

1.  Those  containing  cholesterin  with  or  without  pigment; 

2.  Those  composed  of  bilirubin  in  combination  with  calcium :  they 
are  dark  colored  and  amorphous  ; 

3.  Small  dark-colored  stones  having  a  mulberry  shape,  consisting 
not  of  bilirubin  itself,  but  of  one  or  another  derivative  of  bilirubin  ; 

4.  Gall-stones  consisting  almost  entirely  of  inorganic  salts  ;  calcic 
carbonates  and  phosphates  are  also  occasionally  met  with  (Foster). 

Clinically,  we  find  gall-stones  most  frequently  in  persons  of  seden- 


30O  SURGICAL    DIAGNOSIS  AND    I'A'IiATMENT. 

taiy  habits  who  arc  given  to  excessive  eating  and  drinking.  Females 
are  more  Hable  to  the  affection  than  males,  possibly  owing  to  a  tendency 
to  osteomalacia,  a  disease  which  tends  to  the  liberation  of  calcium,  and 
hence  to  the  precipitation  of  cholesterin,  as  suggested  by  some  authors, 
but  more  likely  on  account  of  their  sedentary  habits  and  changes  in  ab- 
dominal pressure  resulting  from  tight-lacing,  pregnancy,  etc.  The  num- 
ber of  stones  which  may  be  found  in  a  gall-bladder  varies  from  a  single 
one  to  seven  thousand.  A  law  which  seems  to  prevail  is  that  when 
few  stones  exist  these  are  of  large  size ;  when  they  are  numerous  their 
size  is  always  small.  They  generally  have  facets,  which  are  the  result 
of  the  pressure  of  the  stones  against  each  other,  and  this  feature  is 
important  in  the  operation  of  cholelithotomy,  for  if  a  single  stone  be 
removed  which  has  one  or  more  facets,  we  may  be  sure  others  are  near 
at  hand. 

Syinptonis. — The  symptom  which  plays  tne  leading  role  in  a  typical 
case  of  gall-stones  \?,  paroxysmal  pain,  which,  from  its  resemblance  to 
the  spasmodic  pain  so  common  in  the  colon,  has  been  named  gall- 
stone or  hepatic  colic.  This  pain  is  due  in  part  to  inflammation  pro- 
duced in  the  gall-bladder,  the  ducts,  and  adjacent  parts  by  the  irritation 
of  the  stones  ;  also  to  the  obstruction  of  the  ducts  during  the  passage 
of  the  calculi,  and  to  the  strong  contraction  of  the  gall-bladder  in  its 
efforts  to  overcome  obstruction.  The  pain  is  paroxysmal  in  character, 
and  may  last  for  a  period  varying  from  several  hours  to  two  or  three 
days.  It  is  referred  to  the  region  of  the  gall-bladder,  to  the  epigas- 
trium and  right  hypochondrium,  and  it  is  also  felt  in  the  shoulders  and 
back.  It  is  attended  by  fever,  and  the  patient  will  probably  tell  you 
that  he  is  "  subject  to  such  attacks." 

The  second  symptom  is  the  existence  of  a  tumor,  which  is  identified 
as  the  gall  bladder.  The  normal  position  of  this  reservoir  is  at  the 
anterior  sharp  edge  of  the  liver  in  close  relation  with  the  ninth  costal 
cartilage.  Definitely  to  localize  it,  the  best  landmark  is  the  tip  of  the 
cartilage  of  the  tenth  rib.  Immediately  beneath  this  lies  the  fundus  of 
the  gall-bladder. 

What  causes  enlargement  of  the  gall-bladder  ?  It  is  the  permanent 
occlusion  of  the  ducts.  So  long  as  the  cystic  and  common  ducts  are 
free  no  enlargement  of  the  gall-bladder  takes  place,  unless  it  be  per- 
manently enlarged  from  the  enormous  size  of  its  contained  calculi. 
But  let  either  of  these  ducts  become  occluded  and  the  bladder  will 
soon  enlarge.  This  enlargement  follows  a  definite  line,  which  is  of 
great  diagnostic  importance — that  is  to  say,  from  the  normal  position 
of  the  cyst  toivard  the  iimbi/iais.  If  not  too  large,  the  tumor  rises  and 
falls  with  the  liver  in  the  movements  of  respiration. 

The  third  symptom  is  jatmdicc.  This  symptom  is  not  present  in 
every  case,  and  the  reason  is  very  clear.  If  the  cystic  duct  be  ob- 
structed, the  flow  of  bile  from  the  gall-bladder  is  stopped,  the  cyst 
becomes  over-distended,  but  the  flow  of  bile  from  the  liver  passes 
down  the  hepatic  and  common  ducts  without  hindrance,  and  tJiere  is 
710  Jaundice.  There  is  a  possible  exception  to  this  rule,  as  pointed  out 
by  Fenger — viz.  that  obstruction  in  the  lower  or  distal  half  of  the 
cystic  duct  may  cause  icterus  from  compression  of  the  hepatic  duct. 
When  the  hepatic  duct  or  the  common  duct  is  obstructed,  the  bile  is 


INJURIES  AND   DISEASES   OF  THE   DIGESTIVE   SYSTEM       3OI 

unable  to  escape  from  either  the  liver  or  gall-bladder ;  it  is  reabsorbed 
and  jaundice  is  the  result.  Jaundice,  then,  is  an  indication  that  either 
the  hepatic  or  the  common  duct  is  obstructed.  Fenger  was  able  to 
prove  by  a  post-mortem  experiment  that  a  small  stone  in  the  common 
duct  acting  as  a  ball  valve  can  stop  the  flow  of  bile  into  the  duodenum. 
This  accou'nts  for  the  remittent  icterus  and  the  frequently  recurring 
attacks  of  icterus  and  colic. 

It  may  at  first  thought  appear  a  very  easy  matter  to  settle  the  ques- 
tion as  to  whether  the  gall-bladder  or  the  kidney  is  the  seat  of  the 
symptoms  just  described,  but  in  actual  experience  I  know  of  no  diag- 
nostic point  that  is  more  difficult.  Take  the  first  symptom,  pain.  In 
many  cases  this  is  not  referred  to  the  position  of  the  gall-bladder,  but 
to  the  epigastrium,  and  if  it  is  accompanied  by  severe  vomiting,  the 
stomach  is  apt  to  receive  attention  and  the  gall-bladder  may  be  over- 
looked. The  pain  may  be  felt  in  the  back,  and  sometimes  the  patient 
finds  difficulty  in  localizing  the  pain.  Pressure  over  the  gall-bladder 
usually  elicits  tenderness,  but  the  same  amount  of  tenderness  may  be 
experienced  when  pressure  is  made  over  the  right  kidney. 

When  we  come  to  consider  the  second  symptom — the  presence  of 
a  tumor — still  greater  difficulties  meet  us.  A  movable  kidney  has  many 
points  of  resemblance  to  a  distended  gall-bladder.  These  points  are 
summarized  by  Morris  as  follows  : 

"  I.  Both  may  be  felt  in  the  loin  or  in  the  right  hypochondrium. 

"  2.  Either  tumor  may  be  capable  of  being  pushed  back  into  the 
loin  or  over  to  the  left  of  the  median  line. 

"  3.  In  both  cases  the  tumor  is  more  or  less  firm,  elastic,  and 
smooth — either  very  tender  or  not  at  all   so. 

"  4.  In  either  case  it  may  be  round  or  oval,  or  shaped  like  an  o.^^^ 
a  pear,  an  orange,  or  a  sausage. 

"  5.  Each  may  present  a  smooth,  firm,  and  rounded  projection  on 
its  surface — in  the  case  of  the  kidney  due  to  a  cyst  beneath  the  front 
of  the  capsule ;  in  the  case  of  the  gall-bladder,  to  a  calculus  in  a  pouch 
in  its  anterior  wall. 

"  6.  Both  may  have  either  a  resonant  or  a  dull  note  on  percussion 
in  front. 

"  7.  Both  may  give  rise  to  various  dyspeptic  symptoms — nausea, 
flatulence,  and  constipation. 

"  8.  Either  may  give  rise  to  paroxysmal  attacks  of  severe  colic,  the 
maximum  intensity  of  which  is  referred  to  the  situation  below  the  ribs 
on  the  right  side  of  the  abdomen.  In  enlarged  gall-bladder  these 
attacks  are  due  to  the  sudden  impaction  of  a  gall-stone  in  the  cystic  duct 
— in  movable,  kidney,  to  kinking  or  rotation  of  the  ureter  or  renal 
vessels. 

"  9.  Either  may  give  rise  to  jaundice,  gastric  and  intestinal  catarrh. 

"  10.  With  either  there  may  be  considerable  displacement  of  the 
colon  and  small  intestine,  or  adhesions  and  matting  together  of  the  in- 
testines and  omentum  in  front  of  the  intestine  may  occur. 

"II.  In  neither  case  does  the  condition  of  the  urine  help  us,  as 
there  may  be  albumin  with  distended  gall-bladder  or  bile  in  the  case 
of  movable  kidney." 

Further  to  increase  the  difficulty  which  attends  the   diagnosis  of 


302  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

these  cases,  a  gall-bladder  may  be  elongated  and  curv^ed  in  such  a  way 
that  it  has  a  kidney  shape,  or  the  liver,  being  pushed  downward,  causes 
the  elongated  gall-bladder  to  turn  backward,  giving  the  appearance  of 
a  tumor  in  the  right  lumbar  region.  The  kidney,  on  the  other  hand, 
may  simulate  the  gall-bladder.  It  may  be  adherent  to  the  liver,  so  that 
when  pushed  toward  the  left  and  back  again  to  the  loin,  its  connection 
with  the  liver  is  still  maintained,  and  the  resemblance  to  a  distended, 
elongated  gall-bladder  be  perfect. 

When  we  look  for  help  in  other  directions,  we  meet  with  disappoint- 
ment. Movable  kidney  occurs  seven  to  nine  times  more  frequently  in 
women  than  in  men  ;  gall-stones  have  a  preference  for  the  sex  in  about 
the  same  proportion.  Both  affections  often  coexist  in  the  same  individ- 
ual, and  both  are  most  frequently  found  in  women  who  have  large 
families.  It  is  a  fact  not  to  be  lost  sight  of  that  a  movable  kidney  may 
be  a  cause  of  gall-stones. 

Tiicse  statements  are  rather  discouraging,  and  yet  a  careful  investi- 
gation will  usually  lead  us  to  a  correct  conclusion. 

The  following  points  will  help  us  : 

1.  A  gall-bladder  if  enlarged  is  inclined  to  grow  in  the  direction  of 
the  umbilicus,  and  on  careful  palpation  it  can  be  traced  to  its  connection 
with  the  liver.  Tracing  it  up  to  the  liver  and  holding  two  fingers  of 
the  left  hand  on  this  point,  move  the  lower  end  of  the  tumor  with  the 
right.  The  point  at  the  junction  with  the  liver  is  a  fixed  point,  while 
the  rest  of  the  tumor  moves  as  a  pendulum. 

2.  On  deep  inspiration  the  tumor  movies  downward  with  the  liver 
and  rises  with  expiration. 

3.  Jaundice,  either  attending  or  following  paroxysmal  attacks  of 
pain,  is  very  strong  evidence  of  gall-stones. 

4.  While  a  sudden  diminution  of  the  size  of  the  tumor  may  occur  in 
either  case,  we  may  consider  it  positive  evidence  that  the  tumor  is  a 
kidney  if  the  decrease  in  size  is  attended  with  a  sudden  and  copious 
flow  of  urine,  or  that  it  is  a  gall-bladder  if  the  stool,  previously  clay- 
colored,  suddenly  shows  an  excess  of  bile. 

5.  A  gall-bladder  filled  with  calculi  is  much  harder  than  a  movable 
kidney.  It  is  more  tender,  and  in  rare  instances  a  grating  of  the  stones 
can  be  felt  on  palpation. 

A  very  difficult  problem  arises  when  a  distended  gall-bladder  rests 
upon  the  anterior  surface  of  a  slightly  displaced  kidney  in  such  a  way 
that  on  double  palpation  a  tumor  is  felt  to  extend  from  the  lumbar 
region  to  the  anterior  abdominal  wall.  If  the  history  of  jaundice  and 
other  symptoms  pointing  to  the  gall-bladder  fail  us,  we  can  some- 
times settle  the  question  by  finding  on  palpation  that  the  gall-bladder 
has  an  independent  movement. 

Stone  in  the  kidney  is  another  condition  which  is  frequently  difficult 
to  distinguish  from  gall-stones.  Our  main  reliance  must  be  placed 
upon  two  points  : 

1.  A  microscopic  examination  of  the  urine  is  almost  sure  to  reveal 
the  presence  of  blood-  and  pus-corpuscles,  which  is  strong  evidence 
that  the  kidney  is  the  affected  organ. 

2.  Tenderness  over  the  kidney.  This  tender  point  is  found  by 
making  deep  pressure  inward  at  the  outer  edge  of  the   erector  spina; 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE   SYSTEM.       303 

muscle  at  the  lower  border  of  the  twelfth  rib.  The  edge  of  the  muscle 
is  about  two  inches  from  the  spines  of  the  vertebrae.  It  must,  however, 
be  remembered  that  the  kidney  and  gall-bladder  are  close  together, 
and  that  in  the  case  of  a  gall-stone  inflammation  of  the  peritoneum  and 
other  tissues  in  its  vicinity  is  common.  Hence  pressure  from  the  loin 
is  a  source  of  pain,  even  in  gall-stones. 

A  tongue-shaped  elongation  of  the  right  lobe  of  the  liver,  produced 
by  tight  lacing,  may  simulate  an  enlarged  gall-bladder.  The  direction 
in  which  the  tumor  points  and  the  breadth  of  its  attachment  to  the 
liver  should  be  sufficient  to  differentiate  them. 

Gastric  ulcer  may  be  confounded  with  gall-stones.  The  diagnosis 
must  rest  upon  the  presence  of  blood  in  the  vomited  matter,  vomiting 
coming  on  almost  immediately  after  taking  food,  and  the  existence  of 
a  tender  spot  in  the  stomach.  In  every  case  of  this  kind  a  test- 
breakfast  should  be  given  and  the  stomach-contents  examined. 

Carcinoma  of  the  stomach  should  not  cause  much  confusion,  for 
here  we  have  the  coffee-ground  vomiting,  the  presence  of  a  tumor,  and 
the  absence  of  hydrochloric  acid  in  the  stomach-contents.  Disease  of 
the  pancreas  frequently  simulates  gall-stones,  and  especially  when  a 
tumor  presses  upon  the  common  bile-duct — a  condition  which  may 
render  the  diagnosis  impossible. 

Sounding  for  gall-stones  by  exploratory  puncture,  although  ad- 
vocated from  time  to  time,  is  a  proceeding  which  is  attended  with  risk, 
and  cannot  be  spoken  of  with  any  favor. 

Diag}iosis  of  tJic  Position  of  the  Stone. —  i.  /;/  the  Gall-bladder. — 
Judging  from  the  number  of  cases  in  which  stones  are  found  in  the 
gall-bladder  post-mortem,  it  is  evident  that  they  can  exist  for  an 
indefinite  time  without  producing  symptoms.  According  to  Fiirbringer, 
their  presence  can  only  be  manifested  when  they  become  displaced  by 
violent  movements  of  the  body,  by  contractions  of  the  abdominal 
wall,  or  by  increased  secretion  of  the  mucous  walls  of  the  gall-bladder 
induced  by  the  irritation  of  the  stones. 

While  the  stones  are  confined  to  the  gall-bladder,  it  is  doubtful  if 
we  ever  find  pronounced  hepatic  colic.  There  is  pain,  but  not  of  the 
severe  paroxysmal  type.  It  is  only  when  obstruction  of  the  cystic  duct 
takes  place  that  the  typical  colic  occurs.  The  diagnosis  of  stones  in 
the  gall-bladder  must  rest  upon  the  following  points :  pain  in  the 
epigastrium  and  the  right  hypochondrium,  gradually  increasing  in 
severity,  and  often  radiating  to  the  angle  and  inner  margin  of  the 
scapula.  There  is  a  slight  rise  in  temperature,  not  exceeding  99.5°  F. ; 
the  stomach  is  disturbed,  but  vomiting  may  be  slight  or  absent. 

On  palpating  the  position  of  the  gall-bladder  a  sensitive  spot  is  felt, 
especially  on  deep  inspiration.  There  is  no  jaundice,  for  the  bile  is  not 
impeded  in  its  flow  from  the  liver  through  the  hepatic  and  common 
ducts  to  the  duodenum.  If,  however,  a  stone  escapes  from  the  gall- 
bladder and  passes  through  the  cystic  and  common  ducts  into  the 
intestine,  temporary  jaundice  will  result,  depending  upon  the  transient 
obstruction  in  the  common  duct.  In  every  case  of  supposed  gall- 
stones the  feces  should  be  examined  for  stones  that  may  have  passed. 

No  tumor  can  be  felt  unless  the  gall-bladder  is  enlarged  by  the  im- 
mense size  and  number  of  the  stones  or  by  the  presence  of  pericystitis. 


304  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

2.  [)i  the  Cystic  Duct. — There  is  hepatic  colic,  which  reaches  its 
heijj^ht  in  two  or  three  hours,  and  stops  suddenly,  provided  the  stone 
falls  back  into  the  gall-bladder.  Nausea  and  vomiting  are  nearly  always 
present.  On  palpation  the  muscles  over  the  hypochondrium  are  found 
to  be  rigid,  and  the  movements  of  the  diaphragm  are  restricted,  causing 
rapid  and  shallow  respiration.  The  gall-bladder  may  or  may  not  be 
distended,  and  there  is  no  jaundice  unless  the  stone  occupies  the  lower 
half  of  the  cystic  duct,  in  which  case  it  may  press  upon  the  hepatic 
duct,  and,  preventing  the  flow  of  bile  from  the  liver,  result  in  jaundice. 

3.  /;/  the  Covinwn  Duct. — There  is  no  tumor,  abscess,  or  local 
tenderness  in  the  position  of  the  gall-bladder,  unless  coincident  in- 
flammation is  present  (Fenger).  The  pain  is  in  the  epigastrium  or  in 
the  back.  Sometimes  the  stone  acts  as  a  ball  valve  (Osier,  Fenger), 
the  evidence  of  which  may  be  inferred  when  a  change  of  position 
causes  relief  of  pain,  or  when  there  is  remittence  of  pain  with  sudden 
subsidence,  attended  with  flow  of  bile  and  without  discharge  of  stone.' 
Icterus  is  the  leading  symptom,  and  is  always  inseparable  from  obstruc- 
tion.    It  is  either  intermittent  or  remittent  in  character. 

Colic  is  an  almost  constant  symptom,  varying  in  character  and 
duration.  If  a  stone  becomes  impacted,  colic  is  continuous,  but  this  is 
relatively  rare.  When  the  stone  floats  in  the  dilated  duct,  the  attacks 
of  colic  are  remittent.  If  it  passes  into  the  duodenum,  the  attack  of 
colic  is  transient.  Pain  may  come  on  slowly  or  suddenly.  It  may  last 
for  a  considerable  time,  and  disappear  abruptly.  Nor  is  it  always  felt 
in  the  region  of  the  gall-bladder,  unless  that  viscus  is  inflamed,  but  is 
found  in  the  lower  dorsal  region,  in  both  hypochondriac  regions,  and  in 
both  lumbar  regions,  and  may  be  relieved  or  ended  by  change  of  posi- 
tion. Vomiting  is  common  from  the  absorption  of  bile  ;  fever,  either  of 
an  intermittent  or  a  remittent  type,  is  a  common  symptom.  Rapid  and 
extreme  loss  of  weight  is  due  to  the  same  cause. 

Exploratory  Incision. — There  are  cases  in  which  a  positive  diagnosis 
is  impossible  in  spite  of  the  most  searching  inquiry,  and  nothing  short 
of  bringing  the  parts  under  ocular  inspection  will  clear  up  the  mystery. 
In  many  of  these  obscure  cases  the  diagnosis  lies  between  stone  in  the 
gall-bladder  or  ducts  and  stone  in  the  kidney.  Unfortunately,  the 
incision  which  will  reach  the  gall-bladder  is  not  the  best  to  explore  the 
kidney.  If  we  operate  for  gall-stones  and  find  that  none  exist,  it  then 
becomes  necessary  to  close  the  wound,  turn  the  patient  over,  and  get 
to  the  kidney  by  the  lumbar  incision.  This  I  believe  is  the  wisest  pro- 
gramme to  adopt.  The  gall-bladder  can  be  exposed  to  view ;  it  can 
be  examined  for  stones  by  the  sense  of  touch  without  opening  into  it ; 
evidences  of  inflammation,  recent  or  remote,  will  be  regarded  as  strong 
evidence  of  gall-stones ;  in  the  vicinity  of  the  gall-bladder  the  cystic 
and  common  ducts  can  pass  under  the  same  review,  and  should  no 
stones  be  found  the  only  cutting  has  been  in  the  abdominal  wall.  It  is 
not  so  with  the  kidney.  We  may  manipulate  it,  perforate  it  with 
needles,  and  find  that  nothing  short  of  laying  the  organ  open  will 
reveal  the  calculi. 

Pathological  Changes  produced  by  Gall-stones. — In  a  very  practical 
and  able  paper  on  gall-stone  diseases  read  before  the  Minnesota  Acad- 

^  American   Year-Book  of  Aledicine  and  Surgery,  1897,  p.  182. 


INJURIES  AND  DISEASES   OF   THE  DIGESTIVE   SYSTEM.       305 

emy  of  Medicine,  Dr.  Hoegh  sums  up  the  pathological  changes  as 
follows : 

"  I.  The  gall-bladder  is  usually  the  primary  seat  of  stones.  Excep- 
tionally, they  are  developed  in  the  liver  gall-ducts  when  there  is  stag- 
nation of  bile.  But  the  gall-bladder  is  usually,  even  then,  the  primary 
seat  of  the  illness,  and  its  epithelium  is  always  diseased — sometimes 
certainly  in  a  very  mild  degree,  only  some  desquamation  with  rapid 
regeneration  of  epithelium.  In  such  cases  no  symptoms  appear  during 
life.  But  in  other  cases  there  are  changes  in  the  form,  size,  and  thick- 
ness of  the  walls  of  the  gall-bladder.  The  contents  may  be  more  or 
less  changed.  In  other  cases  the  disease  has  progressed  to  the  cystic 
duct,  where  the  pathological  changes  are  the  same  as  those  in  the  blad- 
der. When  the  disease  stops  here  we  have  only  local  symptoms ;  the 
constitution  suffers  but  little.  The  gall-bladder  may  be  very  much 
changed  in  form  ;  it  may  contain  diverticula,  the  seat  of  concrements ; 
it  may  assume  an  hour-glass  shape ;  it  may  flop  over  to  the  cystic  duct 
and  obstruct  or  obliterate  it ;  it  may  be  atrophic,  barely  of  the  size  of 
the  last  phalanx  of  the  little  finger,  or  it  may  be  large  enough  to  hold 
a  pint ;  the  thickness  of  its  wall  may  be  nearly  an  inch  ;  it  may  be  en- 
crusted with  salts  of  bilirubin-lime,  so  that  a  chisel  may  be  necessary  to 
open  it ;  it  may  be  obliterated,  but  that  is  mostly  after  suppuration  and 
operations.  In  more  than  half  the  cases  the  contents  will  be  found 
changed ;  it  may  be  filled  with  serum,  mucus,  pus,  or  any  mixture  of 
these.  When  there  are  adhesions  to  the  colon  it  may  even  be  putres- 
cent, and  probably  highly  infectious  for  the  peritoneum.  In  about  one- 
half  the  cases  the  stones  are  found  only  in  the  gall-bladder. 

"  2.  The  cystic  duct  is  usually  not  seen  during  the  operation  on 
account  of  its  depth.  If  the  cystic  duct  is  pervious,  the  contents  of  the 
gall-bladder  are  bilious ;  if  the  bile  is  inspissated  or  if  the  contents  are 
pus,  mucus,  or  serum,  it  is  evident  that  the  duct  is  closed.  This  clos- 
ure may  be  due  to  an  impacted  stone,  more  often  to  inflammatory 
swelling,  a  simple  continuation  of  the  inflammation  of  the  gall-bladder 
produced  by  the  presence  of  stones  or  bacteria ;  when  the  stones  are 
removed  from  the  gall-bladder  and  the  latter  drained  so  that  its 
epithelium  becomes  healthy,  this  concomitant  swelling  of  the  cystic 
duct  disappears  ;  when  the  bandage  is  changed  after  a  couple  of  days, 
it  is  found  full  of  bile,  but  no  stone  is  found  to  account  for  the  estab- 
lished communication  between  the  ductus  communis  and  the  gall- 
bladder. 

"  Dilatation  of  the  cystic  duct  is  the  result  of  impaction  of  stones, 
sometimes  in  this  duct  alone,  sometimes  also  in  the  bladder,  ductus 
choledochus,  or  liver ;  a  whole  row  of  stones  may  be  found  in  the 
cystic  duct  arranged  as  beads  on  a  string  ;  a  stone  may  be  forced  into 
the  duct  with  such  violence  that  it  becomes  arrested  at  its  mouth,  which 
it  dilates ;  gravity  may  then  pull  it  down  into  the  gall-bladder,  and  it 
hangs  down  into  it  as  a  polypus  from  a  dilated  os  uteri  hangs  down 
into  the  vagina. 

"  Obliteration  of  the  cystic  duct  is  found  alone  or  with  obliteration 
of  the  gall-bladder. 

"  3.  The  ductus  cJiolcdocluis  next  demands  our  attention.  This  duct 
is  obliterated  only  when  cancerous  infiltration  of  its  walls  or  of  the 
20 


306  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

portal  glands  is  present ;  otherwise  the  constant  flow  of  bile  prevents 
this  taking  place.  Dilatations  are,  on  the  other  hand,  common  from 
stones,  especially  when  they  become  arrested  at  the  papilla.  This  dila- 
tation has  been  so  great  that  the  duct  has  been  mistaken  for  the  gall- 
bladder, and  has  been  sewed  into  the  abdominal  wall.  Stones  may  be 
found  only  in  the  ductus  choledochus,  or  at  the  same  time  also  in  the 
other  bile-ducts.  The  contents  of  this  duct  do  not,  like  those  of  the 
bladder,  become  changed  to  pus,  serum,  or  mucus.  They  are  always 
bilious,  but  may  be  more  or  less  inspissated  in  case  of  impacted  stones. 

"  4.  The  Liver. — After  death  this  organ  is  always  found  smaller  than 
was  supposed  during  life  when  its  distention  depends  upon  engorgement 
by  blood  or  bile.  It  must  also  be  remembered  that  the  liver  frequently 
is  rotated  upon  its  transverse  axis,  and  thus  offers  an  abnormally  large 
surface  to  the  examining  hand ;  this  takes  place,  for  instance,  when  the 
right  kidney  draws  or  pushes  it  down.  It  may  be  very  difficult  to 
establish  the  lower  border  of  the  right  lobe  of  the  liver,  especially 
when  it  is  soft  and  the  abdominal  wall  thick  from  fat.  Palpation  with 
a  light  hand  yields  usually  a  better  result  than  percussion,  which  only 
rarely  can  demonstrate  a  thin,  atrophic,  and  wedge-shaped  liver  margin 
or  an  elongated  process  of  the  right  lobe,  which  is  not  uncommonly 
associated  with  chronic  gall-stone  disease.  By  pressing  from  the 
lumbar  region  with  the  left  hand  and  gently  feeling  with  the  right 
one  laid  flat  upon  the  abdomen  the  sharp  lower  margin  may  be  felt. 
Inspection  will  sometimes  give  valuable  information.  It  is  to  be 
expected  that  enlargements  of  the  liver  are  most  common  where 
the  deeper  bile-ducts  are  inflamed  and  impervious  ;  a  tongue-shaped 
process  over  the  gall-bladder  in  an  almost  vertical  direction  is  fre- 
quently found ;  in  extreme  cases  this  process  reaches  as  low  and 
even  lower  than  a  line  from  the  navel  to  the  anterior  iliac  spine.  The 
form  of  the  liver  shows  many  anomalies  which  seem  to  be  connected 
with  the  gall-stone  disease ;  for  instance,  hypertrophy  of  the  anterior 
lobe,  a  deep  notch  instead  of  the  usually  rather  shallow  incisura  vesi- 
calis,  striking  development  in  the  vertical  dimensions  of  the  liver  at  the 
expense  of  its  transverse  diameter.  The  consistency  of  the  liver  is 
occasionally  changed,  sometimes  harder,  sometimes  softer,  than  in 
health.  In  exceptional  cases  we  must  be  prepared  to  find  throm- 
bosis of  a  branch  of  a  portal  vein  which  may  lead  to  great  swelling, 
to  enlargement  of  the  hepatic  ducts,  even  with  formation  of  concre- 
ments  within  the  same.  The  liver  may  be  partly  atrophic,  especially 
where  it  is  overlying  a  gall-bladder  filled  with  stones.  Like  the  other 
biliary  organs  and  the  adjacent  viscera,  the  liver-surface  may  show 
signs  of  inflammation,  new  or  old ;  there  may  be  deposits  of  fibrin 
and  more  or  less  firm  adhesions  to  the  omentum,  the  adjacent  abdom- 
inal wall,  the  duodenum,  or  the  stomach,  thus  producing  changes  in  these 
organs  and  interfering  with  their  functions ;  thus  in  a  case  reported  by 
Kehr  adhesion  to  the  stomach  had  produced  dilatation  of  this  organ, 
with  all  its  disastrous  symptoms,  which,  however,  w^ere  relieved  by 
successful  operation. 

"  This  leads  us  to  the  consideration  of — 

"  5.  TJie  adjacent  intestines,  which  frequently  (nay,  perhaps,  more  fre- 
quently than  the  regular  gall-stone  colics)  give  rise  to  those  disturbances 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE   SYSTEM.        307 

that  we  have  learned  to  consider  as  depending  upon  the  presence  of 
gall-stones  in  the  biliary  organs.  While  the  adhesions  usually  are  so 
slight  that  they  may  be  easily  broken  up  by  the  mere  pressure  of  the 
tips  of  the  fingers,  they  are  at  other  times  so  firm  that  they  must  be 
dissected  out ;  sometimes  they  are  stronger  than  the  walls  of  the  hol- 
low viscera,  which  may  be  torn.  Under  such  circumstances  careful 
suture  has  saved  the  patient  in  cases  reported  by  Riedel  and  Lauen- 
stein.  Adhesions  have  been  formed  to  the  abdominal  wall  and  to  the 
pleura.  By  the  breaking  through  of  a  circumscribed  pleuritic  em- 
pyema into  a  bronchus  gall-stones  have  been  known  to  be  coughed 
up.  Such  cases  are  of  course  exceedingly  rare,  but  common  are 
adhesions  to  omentum,  colon  transversum,  duodenum,  and  abdominal 
wall." 

Treatment. — Considering  the  frequency  with  which  gall-stones  are 
found  post-mortem,  and  which  cause  no  symptoms  during  life,  there 
must  be  a  large  number  of  cases  in  which  no  ill  effects  are  produced. 
Such  cases,  even  if  diagnosticated,  require  no  treatment.  Medicina- 
remedies  can  be  of  value  only  in  palliating  the  suffering  during  attacks 
of  gall-stone  colic.  No  remedy  has  been  discovered  which  will  prevent 
the  formation  of  stones,  much  less  dissolve  them  after  they  have  been 
formed.  More  satisfaction  can  be  expected  from  remedies  which  are 
given  with  the  object  of  propelling  the  stones  along  the  ducts.  For 
this  purpose  phosphite  of  soda,  turpentine,  rhubarb,  and  the  salicylates 
have  been  commended.  Could  we  determine  the  size  of  the  stones  and 
the  possibility  of  their  passing  through  the  ducts,  this  line  of  treatment 
would  be  rational.  But,  as  a  rule,  we  are  entirely  in  the  dark  as  regards 
the  size  of  a  stone  which  is  causing  colic,  and  should  we  force  it 
onward  we  may  be  doing  the  patient  absolute  harm  by  causing  it  to 
lodge  in  the  common  bile-duct,  where  it  is  infinitely  more  troublesome 
and  dangerous  than  in  the  gall-bladder.  On  this  point  Dr.  Hoegh,  in 
the  paper  already  referred  to,  says  :  "  Where  there  has  been  no  icterus 
I  can  see  no  justification  in  trying  to  push  the  stones  through,  for  they 
must  yet  be  in  the  gall-bladder  or  cystic  duct,  and  thence  they  can  be 
removed  safely  by  surgical  means.  To  subject  a  patient  with  stones 
confined  to  the  gall-bladder  to  the  risk  of  having  them  arrested  in  the 
ductus  choledochus  seems  almost  a  criminal  act.  In  fact,  the  only 
condition  that  I  think  of  that  would  justify  the  use  of  cholagogues 
would  be  that  group  of  cases  in  which  the  disease  begins  suddenly  and 
is  complicated  with  jaundice,  without  such  prodromes  as  epigastric 
oppression,  occasional  cardiac  pain,  or  nausea.  The  absence  of  these 
symptoms  would  indicate  that  the  disease  was  recent  and  the  stones 
small,  and  that  the  jaundice  was  the  result  of  impaction  of  a  small 
stone,  for  if  it  were  caused  by  a  concomitant  inflammation  of  the  ductus 
choledochus,  we  ought  to  hav^e  had  a  train  of  inflammatory  symptoms 
preceding  it." 

Sw-gical  Treatment. — Before  deciding  that  an  operation  is  required 
we  should  endeavor  to  determine  the  position  of  the  stone.  In  the 
vast  majority  of  cases  gall-stones  are  formed  in  the  gall-bladder,  and 
the  operation  for  their  removal  from  this  position  is  safe  and  satisfactory 
in  the  hands  of  experienced  operators.  We  can  come  to  the  con- 
clusion that  the  stone  is  still  in  the  gall-bladder  if  there  are  the  cha- 


308  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

racteristic  attacks  of  hepatic  colic,  no  permanent  distention  of  the  gall- 
bladder, and  no  persistent  jaundice. 

We  can  say  that  it  is  in  the  cystic  duct  if  the  gall-bladder  be  perma- 
nently distended,  without  persistent  jaundice,  notwithstanding  that 
every  attack  of  hepatic  colic  is  followed  by  jaundice  which  is  transitory. 
This  is  due  to  inflammation  in  the  ducts. 

It  is  in  the  ductus  communis  choledochus  if  there  is  persistent 
jaundice,  with  attacks  of  colic  and  with  no  permanent  distention  of  the 
gall-bladder.  "  Attacks  of  severe  pain  in  the  epigastrium  and  right 
hypochondrium,  accompanied  by  vomiting  and  shivering,  and  followed 
by  sweating,  complete  relief,  and  transient  jaundice,  are  due  to  the 
passage  of  a  gall-stone  from  the  gall-bladder  through  the  ducts  into 
the   duodenum." 

"  Careful  washing  of  the  feces  (best  performed  on  a  wire  sieve)  will 
rarely  fail  to  discover  the  stone  or  stones  in  such  a  case  "  (Rutherford 
M  orison). 

High  fever  is  most  frequently  found  in  connection  with  colic  when 
the  stone  is  in  the  common  duct,  and  this  pyrexia  may  assume  an 
intermittent  type,  the  rigors  and  fever  recurring  every  two,  four,  seven, 
or  fourteen  days. 

A  long-standing  case  may  show  a  history  of  a  stone  in  each  of 
these  positions,  or  a  single  case  may  have  mixed  symptoms  due  to  the 
circumstance  of  two  or  more  stones  occupying  different  positions.  Of 
these  positions  the  gall-bladder  is  the  most  favorable,  and  the  aim  of 
the  surgeon  should  be  to  operate  before  the  stone  shall  have  been 
forced  into  either  the  cystic  or  the  common  duct. 

The  operation  of  incising  the  gall-bladder  is  called  cholecystotomy. 
For  the  removal  of  stone  from  the  gall-bladder  cholelithotomy  is  the 
more  correct  term. 

Operation. — An  incision  is  made  over  the  most  prominent  part  of 
the  tumor  if  one  be  present,  or,  if  not,  then  over  the  situation  of  the 
gall-bladder.  To  find  the  gall-bladder  the  tip  of  the  cartilage  of  the 
tenth  rib  is  a  good  landmark.  From  this  point  the  incision  can  be 
made  downward  and  inward  toward  the  umbilicus.  John  B.  Hamilton 
gives  the  following  landmarks  for  the  fundus  of  the  gall-bladder: 
Draw  a  line  from  the  anterior  superior  spinous  process  of  the  ilium  to 
the  center  of  the  xiphoid  cartilage.  Intersect  this  with  a  line  from  the 
umbilicus  to  the  tenth  costo-cartilaginous  juncture.  In  the  right  upper 
triangle  near  the  apex,  but  nearer  the  right  oblique  line,  the  fundus  of 
the  gall-bladder  will  be  found. 

Other  directions  for  the  incision  are — the  vertical,  employed  by 
Lawson  Tait ;  the  transverse,  by  Kocher ;  and  one  parallel  with  the 
line  of  the  ribs,  by  Keen.  I  prefer  the  oblique  incision  of  Greig 
Smith,  separating  the  fibers  of  the  internal  oblique,  thus  lessening  the 
risk  of  ventral  hernia.  If  additional  space  is  required  in  dealing  with 
a  stone  in  the  ducts,  this  incision  can  be  supplemented  with  one  that 
is  transverse,  thus  allowing  the  flap  to  turn  inward.  When  the  peri- 
toneum is  reached  and  all  bleeding  points  stopped  the  membrane  is 
pinched  up  in  the  usual  way  and  divided.  The  edges  of  the  opening 
are  held  apart  with  retractors  while  the  operator  finds  and  examines  the 
gall-bladder.    When  the  cyst  is  small  it  can  readily  be  explored  with  the 


INJURIES  AND  DISEASES   OF   THE  DIGESTIVE  SYSTEM.        309 

fore  finger  and  stones  detected  if  present.  If  the  bladder  is  greatly 
distended,  the  contents  should  be  drawn  off  with  an  aspirator,  the  cyst 
at  the  same  time  being  drawn  up  into,  and  if  possible  partly  outside, 
the  wound.  Sponges  are  packed  around  the  bladder  to  catch  any  fluid 
which  escapes  by  the  side  of  the  trocar.  When  the  fluid  has  drained 
away  sufficiently  the  bladder  is  opened,  and  the  manner  of  opening  it 
must  depend  upon  the  size  to  which  it  is  distended.  A  pair  of  catch- 
forceps  is  applied  on  each  side  of  the  trocar  and  an  opening  made 
large  enough  to  admit  the  fore  finger.  It  must  be  borne  in  mind  that 
as  the  bladder  is  emptied  it  is  drawn  upward  by  the  contraction  of  its 
walls.  The  opening  in  it  must  be  made  low  down,  so  that  it  will  not  be 
drawn  above  the  parietal  opening.  The  finger  in  the  bladder  searches 
for  stones,  and  directs  forceps  or  spoons  which  are  used  for  their 
removal.  When  the  calculi  are  confined  to  the  gall-bladder  their 
removal  is  generally  an  easy  task,  but  when  the  cystic  duct  is  the  seat 
of  a  stone  its  removal  is  often  exceedingly  troublesome. 

Removal  of  Stones  froui  the  Cystic  Duct. — The  fact  that  a  gall- 
bladder is  distended  may  be  taken  as  proof  that  its  neck  or  the  cystic 
duct  is  obstructed  by  a  stone.  With  the  fore  finger  of  one  hand  held 
upon  the  duct  at  the  site  of  the  stone,  a  narrow-bladed  dressing-forceps 
can  be  passed  into  the  duct  and  guided  to  the  obstructing  calculus. 
The  forceps  is  then  made  to  chip  ofl"  pieces  of  the  stone  w^hile  the 
finger  pushes  it  toward  the  bladder  or  into  the  jaws  of  the  instrument. 
Should  this  measure  fail,  the  duct  should  be  incised,  the  stone  removed, 
and  the  opening  in  the  duct  treated  as  in  the  case  of  the  common  duct 
presently  to  be  described.  Crushing  the  stone  by  padded  forceps  out- 
side the  duct-walls,  as  first  advocated  by  Tait,  is  not  now  considered 
good  practice.  Stones  which  could  not  be  removed  from  the  cystic 
duct  or  neck  of  the  gall-bladder  have,  in  a  few  instances,  been  dissolved 
by  injections  of  hot  water  or  olive  oil  through  the  fistulous  opening  in 
the  bladder,  but  such  treatment  is  not  to  be  relied  upon.  After  all 
stones  have  been  removed,  the  next  step  is  to  stitch  the  bladder  to 
the  abdominal  wound.  In  my  first  operation  I  followed  the  teach- 
ing then  in  vogue,  and  united  the  edges  of  the  bladder-incision  to 
the  skin  by  a  continuous  silk  suture.  The  skin  was  inverted,  and  the 
result  w^as  a  biliary  fistula  which  gave  no  end  of  trouble.  Since  that 
time  some  operators  appear  to  have  gone  to  the  other  extreme,  and 
are  satisfied  with  stitching  the  edges  of  the  bladder  opening  to  the 
edges  of  the  incision  in  the  peritoneum  only.  This  is  unsafe.  The 
peritoneum  is  too  thin  and  delicate  a  structure  to  prevent  the  contents 
of  the  gall-bladder  from  getting  into  the  abdominal  cavity.  Were  we 
sure  that  the  flow  consisted  of  pure  bile  (an  aseptic  fluid),  it  might  mat- 
ter little  if  some  of  it  trickled  through,  but  if  pus  or  other  infectious 
fluids  are  present,  even  a  stitch-hole  is  sufficient  to  afford  entrance  and 
result  fatally.  The  stitches  which  secure  the  gall-bladder  to  the  parietal 
ivound  should  include  gall-bladder,  peritoneum,  conjoined  tendon,  and 
some  muscular  tissue.  This  will  effectually  shut  off  the  peritoneal 
cavity  and  give  a  good  granulating  surface  for  the  closing  of  the  fistula. 
A  drainage-tube  is  now  placed  in  the  gall-bladder  and  held  in  position 
by  a  stitch  to  the  skin,  the  parietal  wound  shortened  by  several  silk- 
w^orm-gut  stitches,  and  a  dressing  applied.     The  dressing  is  changed  as 


3IO  SURGICAL   DIAGNOSIS  AXD    TREATMENT. 

often  as  necessary,  and  the  stitches  are  removed  about  the  fifth  day. 
The  draina<;e-tube  is  left  till  the  discharge  is  greatly  diminished ;  it  is 
then  withdrawn  and  the  fistulous  opening  allowed  to  heal  up. 

CJiolclitJiotoniy  in  Tivo  Stages. — When  circumstances  permit,  much 
risk  will  be  averted  by  operating  in  two  stages  : 

1.  The  abdomen  is  opened  as  before,  the  peritoneum  incised,  and  a 
thorough  examination  made  of  the  bladder  and  both  cystic  and  com- 
mon ducts.  If  satisfied  that  the  stones  are  confined  to  the  bladder  and 
both  ducts  free,  the  gall-bladder  is  stitched  by  a  row  of  sutures,  as  in 
the  former  operation,  and  left  unopened.  A  piece  of  gauze  is  placed  in 
the  wound,  and  the  patient  sent  back  to  bed  for  four  or  five  days,  at  the 
end  of  which  time  the  bladder  is  firmly  adherent  to  the  abdominal 
wound  and  the  peritoneal  cavity  completely  shut  off. 

2.  The  gall-bladder  is  now  incised,  the  stones  removed,  a  drainage- 
tube  inserted,  and  the  wound  treated  as  before. 

Removal  of  the  Stones  from  the  Common  Duct. — Three  different 
procedures  have  been  advocated  for  the  relief  of  this  condition  : 

I.  Crushing  the  stone  by  padded  forceps  outside  the  duct  (Tait). 
This  method  is  incomplete  and  attended  with  danger.  It  cannot  be 
considered  a  rational  treatment. 

II.  Cholecystenterostomy ,  or  the  establishment  of  an  opening  between 
the  gall-bladder  and  the  intestine.  This  diverting  of  the  bile  was  sup- 
posed to  serve  every  purpose,  and  with  the  aid  of  Murphy's  button  the 
operation  can  be  so  quickly  performed  that  it  found  favor  in  the  eyes 
of  many  operators.  It  is  open,  however,  to  very  serious  objections, 
which   McGraw  of  Detroit  classifies  as  follows : 

1.  Although  relief  may  follow  the  operation,  the  cause  of  the  dis- 
ease has  not  been  removed,  and  the  stone  which  obstructs  the  duct 
remains  as  a  menace,  causing  irritation  by  its  presence  and  even  lead- 
ing to  suppuration  and  abscess.  The  inflammation  may  spread  even 
beyond  the  duct  and  produce  peritonitis  and  adhesions. 

2.  A  firm  adhesion  is  established  between  the  gall-bladder  and  the 
bowel.  This  must  at  times  produce  great  traction  on  one  or  the  other 
of  these  organs,  interfering  with  their  movement  and  with  the  perform- 
ance of  their  functions.  These  unyielding  adhesions  between  bowel 
and  gall-bladder  may  cause  frequent  attacks  of  pain,  flatulence,  distress 
during  digestion,  and  finally  render  the  patient  liable  to  attacks  of 
obstruction  of  the  bowel. 

3.  After  this  operation  the  stream  of  bile  is  diverted  through  the 
cystic  duct  and  gall-bladder  into  the  bowel.  The  gall-bladder  takes 
upon  itself  the  function  of  the  common  duct,  and  the  common  duct 
becomes  to  all  intents  and  purposes  an  abnormal  gall-bladder,  and 
receives  a  certain  amount  of  bile  which  stagnates  or  crystallizes. 

If,  then,  the  operation  is  attended  with  the  dangers  just  mentioned, 
and  if  we  only  convert  the  common  duct  into  a  gall-bladder  (a  gall- 
bladder containing  a  stone),  the  procedure  cannot  be  compared  with 
an  operation  that  removes  all  cause  of  the  disease  and  leaves  the  parts 
in  perfect  condition.     This  operation  is — 

III.  Incision  of  the  duct,  removal  of  the  stone,  and  drainage.  The 
views  of  surgeons  have  undergone  some  change  in  regard  to  the  danger 
of  incising  the  gall-ducts.     Leakage  of  bile  is  now  regarded  as  of  little 


INJURIES  AND   DISEASES   OF   THE  DIGESTIVE   SYSTEM.       3II 

importance,   provided  it   be   in   its    normal   state   and    free    from    pus. 
Drainage  is  a  safeguard  against  the  consequences  of  sepsis. 

Operation. — The  obhque  incision,  beginning  over  the  ninth  costal 
cartilage  and  extending  downward  and  outward  with  the  splitting  of 
the  internal  oblique  muscle,  is  the  most  suitable.  The  peritoneum  is 
opened  in  the  usual  manner.  The  duct  is  then  exposed  and  incised 
longitudinally  over  the  stone.  After  the  removal  of  the  calculus  a 
sound  can  be  gently  passed  along  the  duct  in  search  of  other  stones, 
which,  if  present,  may  be  pushed  along  to  the  incision,  or  a  new  open- 
ing can  be  made  in  the  duct  for  their  removal.  The  opening  in  the 
duct  is  now  closed  by  two  rows  of  fine  silk  sutures.  This  part  of  the 
operation  is  much  facilitated  if  the  stitches  are  placed  before  the  stone 
is  removed  (see  Fig.  135),  as  recommended  by  Dr.  J.  Wheelock  Elliot 


Fig.  135. — The  duct  is  held  by  thumb  and  finger  of  left  hand. 

the  stone  is  removed  (Elliot). 


The  stitches  are  placed  before 


of  Boston.  If  the  gall-bladder  has  not  been  opened  at  a  previous  stage 
of  the  operation,  this  should  next  be  done,  and  a  careful  search  made 
for  stones  both  in  the  cyst  itself  and  in  the  cystic  duct.  The  bladder 
is  then  stitched  to  the  abdominal  wound,  a  drainage-tube  inserted,  and 
a  copious  dressing  applied.  It  is  not  uncommon  to  find  on  the  dress- 
ings small  stones  or  fragments  which  have  come  away  and  which 
escaped  notice  at  the  time  of  the  operation,  proving  the  value  of  this 
method  of  drainage. 

Operation  xvith  Drainage  of  the  Right  Hypochondrium. — Dr.  Ruther- 
ford Morison  has  described  a  pouch  behind  the  right  lobe  of  the  liver 
which  has  natural  barricades  separating  it  from  the  general  peritoneal 
cavity,  and  he  has  demonstrated  that  efficient  drainage  of  this  pouch 
serves  a  useful  purpose  in  gall-stone  operations.    The  space  is  exposed 


3' 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


by  a  transverse  incision  commencing  over  the  rectus  muscle  an  inch 
below  the  tip  of  the  ninth  rib,  and  extending  back  into  the  loin  midway 
between  the  lower  costal  margin  and  the  iliac  crest.  A  tube  in  the 
lower  angle  of  this  wound  effectually  drains  this  space. 

The  boundaries  of  the  space  are  as  follows :  The  floor  is  formed  by 


Fig.  136. — The  pouch  shown  by 
drawing  liver  upward ;  X  in  all  the 
figures  marks  points  for  drainage 
(Morison). 


Fig.  137. — Transverse  section  through  center 
of  pouch  (Morison), 


the  ascending  mesocolon  covering  the  kidney,  duodenum,  and  other 
structures  in  the  posterior  abdominal  parietes  (Fig.  136).  Superiorly, 
the  space  is  bounded  by  the  left  lobe  of  the  liver ;  inferiorly,  by  the 

ascending  layer  of  the  transverse  mesoco- 
lon (Fig.  137)  covering  the  duodenum  in- 
ternally ;  externally,  by  the  peritoneum, 
bringing  the  lumbar  parietes  as  far  down 
as  the  iliac  crest ;  internally,  by  the  peri- 
toneum covering  the  spine  behind,  the  free 
edge  of  the  gastro-hepatic  omentum  in 
front,  and  the  foramen  of  Winslow  be- 
tween the  two  (Fig.  138).  A  varying 
quantity  of  fluid,  roughly  estimated  a  pint, 
may  be  introduced  into  the  pouch  from 
below  before  any  overflow  into  the  gen- 
eral peritoneal  cavity  can  take  place  (Mori- 
son). 

It  is  perhaps  premature  to  condemn  this 
method  of  treatment,  but  it  appears  to  me 
open  to  some  objections : 

1.  The  length  of  the  incision  must  be 
considerable  to  obtain  the  drainage,  and, 
as  it  is  a  transverse  incision,  the  risk  of 
ventral  hernia  is  too  great. 

2.  There  is  no  evidence  to  show  that 
suppuration,  once  established  in  the  pouch,  would  not  spread  to  the 
general  peritoneal  cavity. 


Fig.  138.- 


-Vertical  mesial  section 
(Morison). 


INJURIES  AND   DISEASES   OF   THE  DIGESTIVE   SYSTEM        313 

3.  Drainage  through  the  gall-bladder,  as  already  described,  is  secured 
by  a  much  smaller  incision,  and  appears  to  answer  all  purposes. 

The  method  of  operating  is  as  follows  : 

Operation. — An  incision  beginning  at  the  outer  border  of  the  right 
rectus  muscle,  an  inch  below  the  ninth  costal  cartilage,  is  extended  out- 
ward and  downward  toward  a  point  midway  between  the  costal  margins 
and  the  iliac  crest.  After  arresting  all  bleeding  points  the  peritoneum 
is  opened  and  the  duct  found.  The  portion  of  the  tube  which  contains 
the  stone  is  steadied  on  the  fore  finger  of  the  operator  or  his  assistant, 
and  a  longitudinal  incision  made  in  the  wall  of  the  duct.  The  stone 
having  been  extracted,  the  opening  is  closed  by  a  double  row  of  fine 
silk  sutures.  Dr.  Morison  does  not  suture  the  duct  or  gall-bladder, 
but  places  one  end  of  the  drainage-tube  in  contact  with  the  incision. 
An  examination  of  the  remaining  portions  of  the  common  and  of  the 
cystic  duct  is  then  made,  and  if  no  further  obstruction  is  found  a  drain- 
age-tube is  so  placed  that  one  extremity  is  in  contact  with  the  incision 
in  the  duct  and  the  other  projecting  from  the  posterior  edge  of  the 
abdominal  wound  just  below  the  right  kidney.  The  abdomen  is  closed 
in  the  usual  manner,  beginning  at  the  inner  extremity  of  the  incision 
and  going  outward  to  the  drainage-tube.  Gauze  is  not  a  suitable 
material  for  drainage,  as  it  does  not  absorb  bile  readily.  When  bile 
no  longer  escapes  through  the  tube,  the  latter  can  be  removed  and  the 
opening  allowed  to  close  by  granulation. 

Cholecystectomy,  or  excision  of  the  gall-bladder,  is  indicated  (i)  where 
the  gall-bladder  containing  one  or  more  calculi  is  so  contracted  that  its 
fundus  cannot  be  sutured  to  the  abdominal  wall ;  (2)  where  there  have 
been  perforations  or  ulceration  and  empyema,  and  the  tissues  are  so 
thin  or  so  much  inflamed  that  they  will  not  bear  suturing  (Greig 
Smith). 

The  operation  usually  requires  a  longer  incision  than  cholecystot- 
omy.  The  edge  of  the  liver  is  held  up  by  a  retractor  and  sponges  are 
packed  around  the  seat  of  the  operation.  The  gall-bladder  is  separated 
from  the  liver,  beginning  at  the  fundus  and  going  toward  the  cystic 
duct.  The  bleeding  may  be  free,  but  is  easily  arrested  by  pressure 
or  a  few  ligatures.  The  cystic  duct  is  divided  between  two  ligatures 
and  the  gall-bladder  removed. 

Wounds  of  the  Gall-bladder. — The  gall-bladder  may  be  wounded 
by  cutting  instruments  or  projectiles,  or  it  may  be  perforated  by  ulcera- 
tion, or  ruptured  by  over-distention  or  by  a  blow.  Although  the  escape 
of  pure  bile  is  not  necessarily  harmful,  the  fluid  being  aseptic  and  read- 
ily absorbed,  wounds  of  the  gall-bladder  are  very  fatal.  The  quantity  of 
bile  found  in  the  abdominal  cavity  after  death  in  this  manner  is  some- 
times enormous.  When  rupture  of  an  empyema  occurs  death  is 
inevitable. 

Diagnosis  of  a  stab-wound  of  the  gall-bladder  must  rest  upon  the 
position  and  direction  of  the  wound  and  upon  the  escape  of  bile. 

Treatment. — If  the  wound  is  small,  adhesions  to  neighboring  parts 
may  wall  in  the  escaping  bile,  which  is  soon  absorbed  and  the  wound 
heals.  Large  wounds  are  very  serious  and  require  immediate  opera- 
tion, the  steps  of  w^hich  are  the  same  as  for  the  removal  of  gall-stones. 
Should  there  prove  to  be  a  wound  of  the  portal  vein,  this  vessel  must 


314  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

not  be  tied,  as  ligation  has  always  been  followed  by  death.  The  edges 
of  the  wound  in  the  vein  must  be  united  by  suture. 

Dropsy  of  the  Gall-bladder. — When  the  gall-bladder  is  dis- 
tended it  is  nearly  alwaj's  the  result  of  obstruction  by  gall-stones. 
Much  more  rarely  the  cause  is  a  neoplasm  of  a  neighboring  struc- 
ture, causing  pressure  on  the  cystic  duct,  or  parasites,  hydatids,  or 
worms.  The  contents  of  the  cyst  soon  become  altered,  changing  to 
a  colorless  fluid  consisting  largely  of  mucus.  The  distention  is  gener- 
ally toward  the  umbilicus,  and  a  tumor  may  form  almost  large  enough 
to  fill  the  abdomen.  The  walls  of  the  bladder  become  tense ;  the  sur- 
face is  smooth  and  uniform,  and  generally  painful  to  the  touch. 

Bmpyema  of  the  Gall-bladder. — Sujipu ration  of  the  gall-blad- 
der is  an  occasional  result  of  gall-stones,  and,  according  to  Tait,  it  is 
more  likely  to  occur  when  only  a  few  stones  are  present.  The  tumor 
is  not  usually  large.  The  walls  are  thickened  in  some  parts,  thinned 
in  others,  and  adhesions  to  neighboring  structures  are  the  rule.  Pus 
may  perforate  the  walls  of  the  bladder  and  rupture  into  the  peritoneal 
cavity,  or  if  adhesions  have  formed  in  favorable  positions  the  pus  may 
burrow  through  the  parietes  and  discharge  externally. 

The  diagnosis  of  empyema  is  always  difficult.  A  history  of  acute 
cholangitis,  followed  by  chills  and  other  evidences  of  suppuration,  with 
the  formation  of  a  moderate-sized  tumor  of  the  gall-bladder,  would  be 
reasonable  grounds  for  asserting  that  the  gall-bladder  contained  pus. 

Treatment. — The  only  treatment  to  be  considered  is  cholecystotomy 
with  drainage.  The  greatest  care  must  be  taken  to  prevent  escape  of 
the  cystic  contents  into  the  peritoneal  cavity.  For  this  purpose  sponges 
should  be  carefully  packed  around  the  bladder  before  opening  it,  the 
bladder  should  be  stitched  to  the  abdominal  wound,  and  a  rubber 
drainage-tube  inserted  and  retained  until  all  suppuration  shall  have 
ceased. 

X.   DISEASES  AND  INJURIES  OF  THE  PANCREAS. 

The  pancreas  is  deeply  seated  in  the  abdomen,  and  is  the  most 
inaccessible  of  all  the  organs.  Its  diseases  are  obscure  and  their  diag- 
nosis sometimes  impossible,  yet  the  pancreas  is  by  no  means  beyond 
the  reach  of  surgical  interference.  Many  cases  have  been  successfully 
operated,  and  with  increased  knowledge  of  morbid  conditions  a  much 
wider  field  may  open  up  for  surgical  procedure  in  this  organ. 

The  functions  of  the  pancreas  are — 
(i)  To  emulsify  fat ; 

(2)  To  saponify  fat ; 

(3)  To  peptonize  albuminoids ; 

(4)  To  convert  starch  into  sugar. 

The  appearance  of  fat  in  the  feces  is  an  evidence  that  the  organ  is 
not  performing  the  first  two  of  its  functions,  and  from  a  remote  period 
to  the  present  time  the  appearance  of  fat  in  the  stools  has  been  con- 
sidered one  of  the  most  prominent  of  symptoms  of  pancreatic  disease. 
This,  however,  has  lost  its  significance  of  late  years,  since  it  has  been 
shown  that  free  or  saponified  fat  in  the  feces  may  be  absent  when  there 
is  obstruction  or  failure  of  the  pancreatic  secretion,  and  may  be  present 


INJURIES  AND  DISEASES   OF   THE  DIGESTIVE   SYSTEM.       315 

when  there  is  no  disease  of  the  organ  in  question.  Diabetes  has  a 
closer  relation  to  pancreatic  disease.  Mering  and  Minkowski  have 
shown  that  complete  removal  of  the  pancreas  from  dogs  is  followed 
by  all  the  characteristic  symptoms  of  diabetes  mellitus,  while  incom- 
plete removal  of  the  organ  produces  no  such  result.  Yet  we  find, 
clinically,  that  diabetes  occurs  without  disease  of  the  pancreas,  and  not 
every  case  of  pancreatic  disease  is  followed  by  diabetes. 

A  like  uncertainty  attends  other  symptoms  that  physicians  have 
been  wont  to  rely  upon  in  the  diagnosis  of  pancreatic  disease.  Lipuria, 
or  fat  in  the  urine,  has  been  observed  in  cancer  of  the  pancreas,  but  the 
rarity  of  the  symptom  deprives  us  of  its  value.  Emaciation  is  a  con- 
comitant of  so  many  diseases  that  it  indicates  nothing.  Bronzed  skin, 
salivation,  and  watery  diarrhea  are  now  regarded  as  of  little  diagnostic 
importance. 

Pancreatic  Hemorrhage. — The  etiology  of  this  disease  is 
obscure.  Various  causes  have  been  suggested,  as  traumatism,  the 
corrosive  action  of  the  pancreatic  secretion,  and  certain  nervous 
influences. 

Symptoms. — Hemorrhage  of  the  pancreas  must  be  placed  among  the 
causes  of  sudden  death  in  apparently  healthy  individuals.  The  diag- 
nosis is  not  likely  to  be  made  until  the  profusion  of  the  hemorrhage 
has  produced  collapse.  The  patient  is  generally  a  male,  seldom  under 
forty-five  years  of  age,  apparently  in  good  health  at  the  time,  but  who 
has  been  more  or  less  intemperate  (Fitz).  The  first  symptom  is  gen- 
erally pain,  which  may  be  severe  or  be  simply  felt  as  a  constriction  of 
the  lower  part  of  the  chest  or  upper  portion  of  the  abdomen.  There  is 
a  frequent  desire  to  defecate  or  there  may  be  frequent  stools.  Nausea 
and  vomiting  are  commonly  present.  Death  is  the  common  termination, 
occurring  sometimes  in  thirty  minutes,  at  others  times  being  delayed 
for  thirty-six  hours.  The  suddenness  of  the  death  is  probably  due  to 
pressure  on  the  solar  plexus  and  semi-lunar  ganglia,  with  which  the 
pancreas  is  in  immediate  relation.  If  the  amount  of  blood  is  small, 
recovery  may  take  place  in  from  half  an  hour  to  several  hours.  When 
the  patient  survives  there  is  a  possibility  that  the  attack  may  be  fol- 
lowed by  localized  peritonitis  or  inflammation  in  the  cavity  of  the  lesser 
omentum,  or  the  hematoma  may  be  the  starting-point  of  a  pancreatic 
cyst.  It  is  only  for  the  relief  of  the  latter  conditions  that  surgical 
interference  is  possible. 

Suppuration  and  Abscess  of  the  Pancreas. — Suppurative 
pancreatitis  is  ushered  in  by  severe  pain  in  the  epigastrium  or  abdo- 
men, with  vomiting  and  great  prostration.  About  the  third  day  of  the 
disease  chills  and  a  rise  of  temperature  occur,  and  the  epigastrium 
becomes  swollen,  tympanitic,  and  tender  to  the  touch.  Jaundice  is 
present  in  a  small  proportion  of  cases,  and  the  liver  and  spleen  may  be 
enlarged.  When  an  abscess  forms,  its  presence  may  be  diagnosticated 
by  the  existence  of  a  growing  tumor  and  the  development  of  septic 
conditions.  To  distinguish  between  a  tumor  of  the  pancreas  and  one 
of  the  stomach  the  latter  organ  may  be  inflated.  As  the  disease  is 
fatal  within  a  few  wrecks  or  months,  an  operation  for  the  opening  and 
drainage  of  the  abscess  is  justifiable. 

Cysts    of  the    Pancreas. — Cysts    of  the   pancreas    are    due   to 


3l6  Si'KGICAL   DIAGiVOS/S  AND    TREATMENT. 

obstruction  of  the  duct  of  Wirsung  or  its  branches  by  either  con- 
traction, obliteration,  or  the  impaction  of  calculi.  It  has  been  suggested 
that  many  of  these  cysts  are  due  to  an  extension  of  an  inflammatory 
process  from  the  duodenum  into  the  duct  of  Wirsung,  by  which  the 
latter  is  obstructed.  Traumatism  must  also  be  recognized  among  the 
causes.  Besides  those  confined  to  the  ducts,  the  term  "  cyst  of  the 
pancreas  "  has  been  applied  to  all  cysts  occurring  in  the  cavity  of  the 
lesser  omentum,  some  of  them  probably  due  to  localized  peritonitis. 

Men  suffer  from  the  disease  more  frequently  than  women,  and  the 
period  of  life  most  liable  is  from  thirty  to  fifty. 

Symptoms. — The  tumor  makes  its  appearance  above  the  umbilicus 
and  between  the  upper  and  middle  zones  of  the  abdominal  cavity.  It 
grows  rapidly,  and  is  often  accompanied  by  gastro-intestinal  symptoms, 
as  vomiting  and  diarrhea.  The  tumor  is  tense  and  elastic  on  palpation. 
It  projects  forward,  pushing  the  spleen  to  the  left,  the  stomach  to  the 
right,  and  the  colon  downward.  Sometimes  the  pulsation  of  the  aorta 
is  communicated  to  the  neoplasm,  suggesting  aneurysm.  In  some 
cases  it  moves  up  and  down  with  respiration.  Fluctuation  can  be  felt 
in  favorable  cases.  Celiac  neuralgia,  diabetes,  a  muddy  complexion, 
and  salivation  have  been  set  down  as  symptoms,  but  their  significance 
is  doubtful.  In  making  a  diagnosis  care  must  be  taken  to  exclude 
distention  of  the  gall-bladder,  hydatids  of  the  liver,  aneurysm  of  the 
abdominal  aorta,  tumor  of  the  kidney,  and  ovarian  cyst. 

Tapping  and  examination  of  the  fluid  will  aid  materially  in  deter- 
mining- the  nature  of  the  growth,  but  in  the  hands  of  a  careful  and 
experienced  operator  an  exploratory  incision  is  more  satisfactory.  When 
fluid  is  withdrawn,  it  will  be  found  to  have  the  following  characters  :  It 
digests  starch  and  emulsifies  fat ;  it  contains  a  large  amount  of  sugar 
and  of  serum-albumin ;  and  under  the  microscope  leukocytes,  fatty 
degenerated  epithelial  cells,  cholesterin,  free  fat,  and  acicular  crystals 
are  common. 

Treatment. — Three  methods  of  treatment  have  been  recommended — 
viz.  tapping,  total  extirpation,  and  incision  with  drainage.  Apart  from 
the  danger  which  attends  tapping,  it  is  at  best  only  a  palliative  measure 
and  not  to  be  advocated.  Total  extirpation  is  unwarrantable  from  the 
fact  that  it  is  followed  by  diabetes,  and,  besides,  is  attended  with  ter- 
rible hemorrhage  and  serious  danger.  Incision  with  drainage  is  com- 
paratively safe,  and  has  proved  very  successful. 

Operation. — The  operation  is  very  similar  to  that  employed  for  a 
distended  gall-bladder.  An  incision  is  made  over  the  most  prominent 
part  of  the  tumor  and  the  cyst  exposed.  The  cyst  is  then  sutured  to 
the  abdominal  wall,  the  wound  packed  with  gauze  and  left  for  four  or 
five  days,  at  the  end  of  which  time  adhesions  will  have  formed.  The 
cyst  is  then  opened  with  safety,  washed  out,  and  a  double  rubber 
drainage-tube  inserted.  When  the  operation  is  completed  at  one 
sitting,  the  sac,  after  exposure,  is  aspirated,  pulled  gently  into  the 
wound,  and  incised.  Its  edges  are  then  stitched  to  the  abdominal 
wound  and  the  cavity  drained. 

Cancer  of  the  pancreas  calls  for  little  consideration  from  a 
surgical  standpoint.  By  the  time  the  disease  has  so  far  progressed  as 
to  be  recognized  it  has  generally  invaded  other  organs  and  is  beyond 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE   SYSTEM.       317 

the  reach  of  treatment.  Billroth  has  removed  the  pancreas  for  car- 
cinoma and  the  patient  recovered,  but  this  single  case  scarcely  estab- 
lishes a  precedent.  It  is  generally  conceded  that  an  attempt  to  remove 
the  entire  organ  for  any  cause  is  unjustifiable.  Partial  removal  is, 
however,  another  question.  The  following  indications  for  operation  are 
given  by  Senn :  "  Partial  excision  of  the  splenic  portion  in  cases  of  cir- 
cumscribed abscess  and  malignant  tumors,  in  all  cases  where  the 
pathological  product  can  be  removed  completely  without  danger  of 
compromising  pancreatic  digestion  or  inflicting  abdominal  injury  upon 
important  adjacent  organs. 

"  Ligation  of  the  pancreas  at  a  point  or  points  of  section  should  pre- 
cede extirpation  as  a  prophylactic  measure  against  troublesome  hemor- 
rhage and  extravasation  of  pancreatic  juice  into  the  peritoneal  cavity. 

"  The  formation  of  an  external  pancreatic  fistula  by  abdominal  sec- 
tion is  indicated  in  the  treatment  of  cysts,  abscesses,  gangrene,  and 
hemorrhage  of  the  pancreas  due  to  local  causes. 

"  Abdominal  section  and  lumbar  drainage  are  indicated  in  cases  of 
abscess  or  gangrene  of  the  pancreas  where  it  is  found  impossible  to 
establish  an  anterior  abdominal  fistula. 

"  Thorough  drainage  is  indicated  in  cases  of  abscess  and  gangrene  of 
the  pancreas  with  diffuse  burrowing  of  pus  in  the  retroperitoneal  space. 

"  Removal  of  an  impacted  pancreatic  calculus  in  the  duodenal 
extremity  of  the  duct  of  Wirsung,  by  taxis  or  incision  and  extraction, 
should  be  practised  in  all  cases  where  the  common  bile-duct  is  com- 
pressed or  obstructed  by  the  calculus  and  death  is  threatened  by 
cholemia." 


XI.    INJURIES  AND   DISEASES  OF  THE  SPLEEN. 

Examination. — The  spleen  lies  in  the  left  hypochondrium,  and  in 
the  normal  state  of  the  organ  its  boundaries  are  as  follows  :  From  the 
upper  border  of  the  ninth  rib  to  the  lower  border  of  the  eleventh,  and 
from  the  middle  axillary  line  backward  toward  the  spine.  In  the  nor- 
mal condition  the  organ  cannot  be  palpated,  lying  as  it  does  behind 
the  ribs.  When  greatly  enlarged  it  can  be  palpated  and  the  sharp 
edge  and  rounded  anterior  surface  clearly  felt.  The  notch  in  its  ante- 
rior border  has  long  been  considered  a  sort  of  distinguishing  mark. 
When  examined  by  percussion  the  spleen  is  found  to  be  a  solid  body 
surrounded  by  resonant  organs  except  on  one  side.  Above  is  the 
lung,  in  front  the  stomach,  and  below  is  the  intestine,  while  in  the 
backward  direction  the  dull  sound  is  continued  over  the  dorsal  mus- 
cles. 

Wounds  of  the  Spleen. — Although  the  spleen  is  a  very  vascular 
organ,  wounds  of  its  substance  are  by  no  means  always  fatal.  Guthrie 
has  observed  after  death  cicatrices  in  the  spleen  corresponding  to 
former  wounds.  It  is  not  so  liable  to  injury  as  the  liver,  owing  to  its 
smaller  size  and  greater  depth.  Sword-thrusts  have  been  observed 
rarely,  and  it  has  been  stated  by  Larrey  that  swordsmen  who  use  the 
weapon  with  the  left  arm  are  in  greater  danger  of  sustaining  wounds  of 
the  spleen,  because  they  present  to  the  adversary  the  side  to  which  his 
hand  is  naturally  directed.     Protrusion  appears  to  be  a  favorable  com- 


3l8  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

plication,  as  it  tends  to  lessen  the  danger  of  internal  liemorrhage  and 
peritonitis. 

The  diagnosis  of  splenic  wounds  must  at  the  onset  rest  upon  the 
position,  direction,  and  depth  of  the  penetration.  Hemorrhage  must  be 
judged  of  by  the  effect  produced  upon  the  pulse  and  the  pallor  of  the 
face,  lips,  and  gums,  the  sighing  respiration,  yawning,  fainting,  and 
possibly  the  presence  of  a  steadily  increasing  area  of  dulness  in  the 
most  dependent  part  of  the  abdomen.  Should  the  hemorrhage  be 
slight  or  the  patient  survive  the  immediate  effects  of  the  traumatism, 
peritonitis,  splenitis,  and  abscess  may  appear  at  a  later  period. 

Treatment. — If  the  position,  direction,  and  depth  of  a  wound  should 
lead  you  to  suspect  a  wound  of  the  spleen,  the  injured  side  should  be 
strapped  as  for  fractured  ribs ;  the  patient  should  lie  upon  it  and  be 
kept  perfectly  at  rest.  Iced  drinks  are  recommended  to  distend  the 
stomach  and  cause  pressure  on  the  spleen.  Should  there  be  evidence 
that  profuse  hemorrhage  is  taking  place,  the  abdominal  cavity  should 
be  opened  by  an  incision  in  the  left  linea  semilunaris,  and  the  wound 
in  the  spleen  packed  with  iodoform  gauze  or  the  bleeding  vessels  liga- 
tured. When  the  organ  is  seriously  lacerated  and  other  measures  are 
of  no  avail  the  organ  may  be  totally  or  partially  removed.  Splenec- 
tomy, or  removal  of  the  spleen,  has  been  attended  with  a  mortality  of 
about  80  per  cent.  It  is  indicated  in  severe  wounds  of  the  organ,  in 
certain  tumors  and  cysts,  and  in  cases  of  dislocated  or  movable  spleen. 
For  leukemia  the  operation  is  not  justifiable.  The  great  danger  of 
splenectomy  is  hemorrhage.  The  incision  is  made  in  the  upper  part 
of  the  left  lineae  semilunaris.  After  opening  the  peritoneum  in  the  usual 
manner  the  hand  is  inserted  and  passed  around  the  spleen,  separating 
all  adhesions.  The  organ  is  then  brought  out  through  the  abdominal 
wound,  care  being  taken  to  avoid  twisting  or  dragging  on  the  pedicle ; 
the  lower  extremity  must  be  the  first  to  come  through  the  wound. 
Traction  on  the  pedicle  is  attended  with  shock  and  must  be  carefully 
avoided.  With  this  object  in  view  the  abdominal  parietes  should  be 
pressed  inward  by  an  assistant,  and  the  pedicle  kept  in  as  slight  a  state 
of  tension  as  possible.  Sponges  are  packed  around  the  abdominal 
end  of  the  pedicle.  The  most  important  part  of  the  operation  is  the 
securing  of  the  vessels  of  the  pedicle.  They  are  exceedingly  apt  to 
slip  through  the  ligature,  and  in  spite  of  the  most  painstaking  and 
skilful  ligation  hemorrhage  has  followed  many  of  these  operations. 
Dr.  Greig  Smith  gives  the  following  directions :  "  No  absolute  rule  can 
be  laid  down  as  to  the  management  of  the  pedicle,  but  a  few  guiding 
principles  may  safely  be  enunciated.  Every  divided  vessel,  artery,  or  vein 
should  be  efficiently  and,  as  far  as  possible,  separately  ligatured.  The 
ligature  should  be  tied  while  the  pedicle  is  in  a  state  of  relaxation  ;  the 
tendency  of  a  small  branch  to  retract  after  being  forcibly  elongated  is 
thereby  obviated.  The  veins  should  be  ligatured  as  well  as  the  arteries, 
because  considerable  branches  communicate  with  the  splenic  vein  close 
to  the  site  of  ligation.  If  the  splenic  branches  spread  out  considerably 
before  entering  the  hilum,  if  they  are  numerous  and  intermingled  with 
veins  and  not  easily  isolated,  and  if  the  pedicle  is  not  short,  the  placing 
of  a  broad  temporary  clamp  before  cutting  away  the  tumor  may  be 
found  advantageous.     In  many  cases  it  will  be  found  a  good  plan  to 


INJURIES  AND  DISEASES   OF  THE   DIGESTIVE   SYSTEM^        319 

apply  pressure-forceps  in  pairs — one  pair  after  another — to  each  portion 
of  the  pedicle  which  contains  a  vessel,  and  divide  between  them  till  the 
whole  pedicle  has  been  cut  through.  Then  one  forceps  after  another  is 
picked  up,  and  the  vessel  or  vessels  which  it  grasps  are  deliberately 
tied  at  a  safe  distance  from  the  forceps.  When  each  vessel  has  been 
secured  the  whole  may  be  surrounded  with  a  single  ligature,  tied  with 
moderate  force,  so  as  to  lessen  the  shock  of  the  arterial  pulse  on  the 
distal  ligatures.  Finally,  the  ligatures  are  all  cut  short  and  the  pedicle 
dropped  into  the  cavity.  Sponging,  if  it  is  necessary,  should  avoid  the 
pedicle,  which  may  be  kept  out  of  the  way  by  a  catch-forceps  attached 
to  its  extremity. 

"  The  gastro-splenic  and  diaphragmatic  hgaments  are  dealt  with  in 
the  same  fashion  by  separate  ligatures  ;  the  same  minute  care  need  not 
be  observ^ed,  however.  Adhesions  are  treated  according  to  ordinary 
principles." 

Gunshot  woimds  of  the  spleen,  if  not  extensive,  are  not  necessarily 
fatal,  even  when  the  bullet  lodges  in  the  organ.  In  warfare  this  form 
of  wounds  is  observed  much  more  frequently  than  in  the  incised  or 
punctured  variety,  as  the  American  Civil  War  afforded  only  a  single 
instance  of  incised,  while  thirty  gunshot  wounds  are  recorded.  The 
symptoms  are  obscure,  and  the  diagnosis  must  rest  upon  the  evidence 
of  hemorrhage. 


Fig.  139. — Anterior  view  of  tumor  of  the 
spleen,  showing  Hnes  of  dulness  (Abbe). 


Fig.  140. — Lateral  view  of  site  and  lines  of  dul- 
ness of  a  tumor  ■of  the  spleen  (Abbe). 


Protrusion  of  the  spleen  through  a  wound  may  require  total  or 
partial  splenectomy. 

Abscess  of  the  spleen  probably  occurs  more  frequently  than  is 
generally  supposed,  owing  to  the  difficulty  with  which  the  condition  is 
recognized.  The  cause  is  traumatism  or  septic  infection.  The  treat- 
ment is  practically  the  same  as  for  abscess  of  the  liver. 


320  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

Rupture  of  the  spleen  may  be  produced  by  violent  blows  or  kicks. 
The  accident  is  usually  fatal  unless  the  or^^an  protrudes  througli  a 
wountl  and  the  protruding  portion  is  ligated  or  removed. 

Cysts  of  the  spleen  are  simple,  hydatid,  or  dermoid,  and  are  almost 
beyond  the  possibility  of  diagnosis  except  by  exploratory  puncture  or 
incision.  The  treatment  consists  of  incision  or  drainage,  as  in  the  case 
of  a  similar  condition  in  the  liver. 

Carcinoma  and  sarcoma  of  the  spleen  may  be  considered  as 
beyond  the  pale  of  surgical  treatment. 

The  areas  of  dulness  in  tumors  of  the  spleen  are  shown  in  Figs. 
139  and   140. 

XII.   DISEASES   AND   INJURIES  OF  THE   RECTUM   AND   ANUS. 

The  history  of  a  rectal  disease,  as  related  by  the  patient,  is  generally 
unsatisfactory  and  unreliable.  One  disease  is  uppermost  in  his  mind, 
and  that  is  "  piles."  If  he  has  pruritus,  he  speaks  of  "  itching  piles." 
If  there  is  hemorrhage  from  the  rectum  due  to  any  condition,  he 
speaks  of  "  bleeding  piles."  There  is  no  class  of  diseases  in  which  so 
little  reliance  can  be  placed  upon  the  patient's  own  statements  as  in  dis- 
eases of  the  rectum.  On  this  account  a  systematic  examination  should 
be  made  in  every  case  and  the  diagnosis  settled  by  the  surgeon's  per- 
sonal observation. 

Mathews  advises  that  the  first  question  put  to  the  patient  should  be, 
Does  the  bowel  protrude  at  stool  ?  This  practically  settles  the  ques- 
tion of  piles  ;  for  if  there  is  no  protrusion,  there  are  no  internal  hemor- 
rhoids that  require  a  surgical  operation.  It  also  settles  the  question  of 
polypi,  for  these  growths  usually  protrude  during  the  act  of  defecation. 

Examination. — For  purposes  of  examination  the  patient  should 
lie  on  his  left  side,  and,  where  it  is  at  all  possible,  he  should  be  pre- 
pared by  having  had  the  bowels  previously  cleared  out  by  a  purgative 
and  the  rectum  washed  by  an  enema.  The  knees  should  be  drawn  up, 
the  body  placed  in  Sims'  position  with  the  back  to  the  light,  and  the 
pelvis  elevated. 

Inspection. — The  condition  of  the  anus  should  be  noted ;  external 
hemorrhoids  or  protruding  internal  piles,  the  opening  of  fistulae,  ulcer- 
ation, eczema,  pruritus,  fissures,  abscesses,  and  condylomata  can  be 
detected  with  the  eye. 

Digital  Examination. — No  instrument  has  ever  been  invented  that 
can  compare  with  the  finger  as  an  aid  to  the  examination  of  the  inte- 
rior of  the  rectum.  The  examining  digit  should  be  well  lubricated 
with  vaselin  and  passed  through  the  sphincter  with  great  gentleness. 
If  the  patient  offers  no  resistance  and  the  surgeon  makes  use  of  a 
boring  motion  with  his  finger,  the  pain  of  this  examination  is  trifling, 
except  where  there  is  serious  disease.  Having  passed  the  finger 
through  the  sphincter,  any  undue  contraction  of  that  muscle  is  to  be 
noted,  and  before  the  digit  is  withdrawn  the  following  questions  must 
be  answered : 

I.  Is  there  stricture  ?  In  the  healthy  rectum  the  finger  can  be  made 
to  sweep  around  a  considerable  space,  and  there  is  nothing  to  impede 
its  progress  when  pushed  in  an  upward  direction.     In  the  case  of  stric- 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE  SYSTEM.       32 1 

ture  a  narrowed  portion  is  reached  through  which  the  finger  may  be 
freely  passed  or  passed  with  difficulty ;  in  any  case  where  stricture 
exists  the  finger  can  readily  detect  it  if  within  reach. 

2.  Is  there  a  tumor  ?  Cancerous  tumors  are  readily  detected  when 
they  are  hard  and  lobulated ;  polypi  are  often  attached  by  long  pedicles 
and  may  reach  up  to  the  sigmoid  flexure,  although  the  insertion  of  the 
pedicle  is  easily  within  reach.  The  patient  should  therefore  be  directed 
to  "  strain  down,"  so  as  to  avoid  this  source  of  error. 

3.  Is  there  an  ulcer  ?  Chronic  ulcers  in  the  rectum  have  indurated 
edges  and  a  good  deal  of  inflammatory  thickening  which  the  examining 
finger  readily  detects. 

4.  In  the  male  the  prostate,  and  in  the  female  the  uterus,  should  be 
carefully  palpated  in  this  examination.  The  prostate,  even  in  health,  can 
be  felt  and  its  lobes  accurately  defined.  If  the  gland  is  found  enlarged 
or  painful  to  touch,  this  fact  should  be  carefully  noted.  The  uterus 
may  be  felt  to  be  retroverted,  and  symptoms  which  were  referred  to 
the  rectum  thus  accounted  for. 

Examination  with  the  Speculum. — Many  different  forms  of  specula 
have  been  invented,  few  of  which  are  of  any  value.  The  best  instru- 
ments are  those  which  contain  least  surface  of  metal  and  permit  a  view 
of  an  extensive  bowel  surface.  Mathews'  self-retaining  rectal  speculum 
(Fig.  141)  seems  to  answer  all  purposes.     For  illumination  direct  sun- 


FlG.  141. — Mathews'  self-retaining  rectal  speculum. 

light  is  the  best,  but  a  forehead  mirror  and  any  of  the  reflectors  used 
by  eye  or  throat  specialists  will  be  useful  when  natural  light  is  not 
obtainable.  By  the  aid  of  the  speculum  the  diagnosis  made  by  the 
finger  can  be  corroborated,  ulcers,  simple,  malignant,  or  syphilitic,  can 
be  studied,  and  the  condition  of  the  mucous  membrane  of  the  rectum 
ascertained. 

Manual  Examination. — Although  this  method  of  examining  the 
rectum  has  been  advocated  by  eminent  authorities,  notably  by  Simon, 
it  must  be  considered  a  dangerous  procedure,  seldom  necessary,  and 


322  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

not  affording  benefit  commensurate  with  the  risk.  In  exceptional  cases, 
however,  it  is  justifiable.  The  hand  of  the  examiner  should  not  exceed 
eight  inches  in  its  greatest  circumference.  The  patient  having  been 
anesthetized,  two  fingers  are  inserted,  then  three,  and  finally  the  five 
digits.  With  a  boring  motion  the  whole  hand  is  finally  passed  within 
the  sphincter  and  up  toward  the  sigmoid  flexure.  It  is  only  in  explor- 
ing the  upper  portion  of  the  rectum  and  lower  end  of  the  sigmoid  flex- 
ure that  the  hand  possesses  any  advantage  over  the  finger. 

Bougies  and  rectal  sounds  are  dangerous  and  of  very  doubtful  utility. 
In  passing  them  up  the  bowel  they  are  almost  sure  to  be  stopped  by  a 
fold  of  mucous  membrane  or  they  impinge  against  the  sacrum. 

Wounds  and  Other  Injuries  of  the  Rectum. — The  commonest 
cause  of  wound  of  the  rectum  is  rupture  of  the  perineum  during  partu- 
rition. The  laceration  extends  through  the  sphincter  ani,  and  seldom 
involves  the  higher  portions  of  the  bowel.  One  case  is  recorded 
(Busche)  in  which  the  child's  head  was  passed  through  the  anus. 
Falls  upon  sharp  or  pointed  instruments  and  the  rough  use  of  a 
bougie  or  the  enema  syringe  have  been  known  to  cause  death  by 
wounding  the  rectum  and  perforating  the  peritoneum.  Such  wounds 
are  generally  septic,  and  are  more  dangerous  when  punctured  than 
when  incised  and  well  drained.  A  violent  effort  to  expel  a  mass  of 
hardened  feces  has  been  known  to  rupture  the  bowel,  but  it  is  doubt- 
ful if  this  has  ever  taken  place  in  a  healthy  rectum.  The  accident  is 
attended  with  sharp  pain  at  the  moment  of  the  rupture,  and  followed 
by  a  discharge  of  blood. 

Wounds  of  the  rectum,  however  produced,  are  liable  to  serious 
complications.  The  hemorrhage  is  often  profuse,  and  may  be  either 
primary  or  secondary.  If  the  wound  be  high  up,  the  peritoneum  is 
perforated,  and  septic  peritonitis  is  an  almost  inevitable  consequence. 
Fecal  matter  infiltrates  the  surrounding  tissues,  invagination  or  hernia 
may  occur,  and  at  a  later  period  .stricture  and  fistula.  When  emphys- 
ema follows  such  a  wound,  as  it  frequently  does,  the  putrid  nature  of 
the  gas  leads  to  diffuse  inflammation  and  septicemia. 

Treatment. — Uncomplicated  wounds  of  the  rectum  may  heal  readily, 
and  an  effort  should  always  be  made  to  obtain  prompt  healing  by  dis- 
infecting the  parts  as  well  as  possible,  by  accurate  approximation  of 
the  lacerated  tissues,  by  frequent  irrigation  with  mild  antiseptic  solu- 
tions, and  by  keeping  the  bowels  at  rest.  Opiates  serve  this  latter 
purpose,  and  lessen  the  danger  of  fecal  infiltration  by  solidifying  the 
stools.  When  there  is  fecal  infiltration  or  imperfect  drainage  the 
sphincter  ani  may  require  free  dilatation  or  incision. 

Foreign  Bodies  in  the  Rectum. — All  sorts  of  bodies  have 
been  found  in  the  rectum,  from  nails,  screws,  and  knitting-needles 
swallowed  by  lunatics  to  the  military  despatches  discovered  by 
Napoleon's  officers  in  the  bowel  of  the  German  soldier.  These  bodies 
are  either  swallowed,  and,  passing  through  the  entire  alimentary  canal, 
are  arrested  in  the  rectum,  or  they  are  pushed  into  the  bowel  by  the 
patient.  They  produce  irritation  and  ulceration  of  the  bowel  which 
may  lead  to  perforation  and  death  by  peritonitis.  For  their  removal 
the  patient  should  be  anesthetized,  the  sphincter  dilated,  and,  if  need 
be,  an  incision   made  through  the  posterior  part  of  the  anus  to  the  tip 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE  SYSTEM.       323 

of  the  coccyx.  This  incision  gives  free  access  to  the  rectum  and 
admits  the  whole  hand  or  instruments  for  the  removal  of  large  objects. 
In  the  case  of  bottles  or  cups  great  care  should  be  taken  to  avoid 
breaking  them,  as  in  such  an  event  the  sharp  fragments  would  produce 
serious  injury  before  they  could  be  removed. 

Hemorrhoids,  or  Piles. — Hemorrhoids  are  dilatations  of  the 
veins  of  the  rectum,  with  more  or  less  infiltration  of  the  connective 
tissue.  The  branches  of  the  superior  hemorrhoidal  vein  in  their  course 
upward  pass  through  little  slits  in  the  muscular  wall.  When  the  mus- 
cle contracts  upon  them  it  causes  obstruction  of  the  caliber  of  the 
vessel,  and  hence  dilatation  below  that  point.  Verneuil  asserts  that 
man  is  liable  to  this  varicose  condition,  owing  to  his  upright  position 
and  to  the  absence  of  valves  in  these  veins.  Persons  are  predisposed 
to  the  condition  who  are  hearty  eaters  and  lead  sedentary  lives.  The 
chief  exciting  causes  are — i.  Conditions  which  obstruct  the  return 
circulation  of  the  rectum,  as  pregnancy,  constipation,  straining  at  stool 
(as  in  dysentery),  pelvic  tumors,  etc.;  2.  Portal  obstruction  due  to 
diseases  of  the  heart,  lungs,  or  liver. 

Two  classes  of  hemorrhoids  are  recognized,  one  class  being  inside, 
the  other  outside,  the  sphincter  muscle.  If  the  veins  inside  the 
sphincter  are  affected  and  protrude  at  stool,  either  remaining  outside  or 
capable  of  being  pushed  back  above  the  sphincter,  they  are  called 
internal  piles.  If  the  affected  veins  are  in  the  submucous  tissue  outside 
the  sphincter,  they  are  external.  In  some  cases  the  external  hemor- 
rhoids are  partially  covered  by  skin  and  partly  with  mucous  mem- 
brane, forming  a  sort  of  mixed  variety,  which  when  inflamed  becomes 
edematous,  infiltrated,  and  very  painful. 

External  piles  occur  in  two  forms  : 

id)  Venons  piles,  which  are  dilated  veins  of  a  purplish  or  reddish 
color,  in  some  cases  causing  little  or  no  trouble ;  in  others  they  are 
inflamed,  tender,  and  produce  excessive  pain  during  defecation.  Some- 
times a  clot  of  blood  is  found  which  may  be  a  thrombus  in  the  lumen 
of  the  vein,  or  a  slight  hemorrhage  into  the  surrounding  tissues  due  to 
the  rupture  of  the  vein  (Mathews). 

{8)  Cutaneous  Piles. — These  are  hypertrophied  folds  or  tags  of  skin 
produced  by  inflammatory  thickening  around  the  affected  veins.  They 
are  often  exceedingly  painful,  but  when  free  from  inflammation  give  no 
trouble.  They  are  usually  a  result  of  the  venous  variety  of  hemor- 
rhoids. 

Treatment. — Although  operative  treatment  affords  the  only  per- 
manent relief,  patients  are  not  always  willing  to  submit  to  it,  and 
palliative  measures  must  be  employed.  Errors  in  diet  must  be  cor- 
rected, highly-seasoned  foods  and  stimulants  being  forbidden.  Hot  or 
cold  applications,  combined  with  rest  in  bed,  are  useful  to  allay  inflam- 
mation. Ointments  of  belladonna  and  opium  have  long  been  favorite 
remedies.  Lotions  containing  carbolic  acid  or  acetate  of  lead  are 
recommended.  Poultices  may  be  employed.  Constipation  should  be 
remedied  by  mild  laxatives,  such  as  cascara,  confection  of  senna  and 
sulphur,  or  the  compound  licorice  powder,  and  when  possible  the 
exciting  causes  should  be  removed.  Regular  habits  of  going  to  stool 
must  be  cultivated. 


324  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

Opcrali\c  treatment  aims  at  a  radical  cure  of  the  condition.  For 
the  cutaneous  wariet)'  excision  is  the  proper  remedy.  The  following  is 
the  operation  recommended  by  Mathews :  A  half-grain  of  the  muriate 
of  cocain  is  injected  under  the  growth  and  five  or  ten  minutes  allowed 
for  its  complete  absorption.  The  tumor  is  then  caught  up  at  its  base 
with  a  pair  of  four-pronged  forceps  and  drawn  firmly  out.  With  a 
sharp  knife  the  skin  is  next  divided  all  around  it,  up  to  the  mucous 
membrane  on  each  side.  A  silk  suture  is  then  thrown  around  the  base, 
tightly  tied,  and  the  tumor  cut  off  close  to  the  thread.  Many  operators 
are  content  to  snip  off  the  protuberant  skin  with  scissors,  controlling 
the  resulting  hemorrhage  by  pressure  and  leavdng  the  wound  to  heal 
by  granulation.  A  neater  operation,  and  one  more  in  accordance  with 
the  surgery  of  to-day,  is  to  treat  the  growth  as  a  simple  tumor,  dis- 
infect the  part,  excise  the  growth  by  a  clean  incision,  stop  all  bleeding, 
close  the  wound  by  a  continuous  catgut  suture,  and  dress  it  with 
iodoformized  collodion. 

The  common  method  of  treating  venous  external  piles  is  as  follows  : 
"  Pinch  up  the  tumor  gently  between  the  finger  and  thumb  of  the  left 
hand,  transfix  its  base  with  a  curved  bistoury,  and  cut  out ;  at  the  same 
moment,  by  pressure  of  the  finger  and  thumb,  the  clot  may  be  extruded. 
Place  a  piece  of  cotton  wool  at  the  bottom  of  the  sac  and  the  operation 
is  completed.  The  pain  soon  subsides,  and  the  patient  makes  a  speedy 
convalescence.  The  incision  should  be  made  in  the  direction  of  the 
radiating  folds  of  the  anus,  and  this  allows  more  completely  of  the 
contraction  of  the  skin  "  (Allingham). 

Internal  hemorrhoids  are  usually  described  as  varicosities  of  the 
middle  and  superior  hemorrhoidal  veins.  This  definition  does  not  fully 
describe  them.  Besides  the  dilated  vein  there  is  always  more  or  less 
infiltration  of  the  surrounding  connective  tissue.  The  vascular  tissue 
need  not  necessarily  be  venous,  for  an  artery  as  large  as  the  radial  is 
sometimes  found  entering  the  base  of  an  internal  pile. 

Allingham  makes  three  classes  of  internal  hemorrhoids — viz.  capil- 
lary, arterial,  and  venous. 

Capillary  hemorrhoids  partake  of  the  character  of  nevi  or  erectile 
tumors,  being  slightly  elevated  above  the  surface  of  the  mucous  mem- 
brane, of  a  granular  appearance,  and  bleeding  freely  on  the  slightest 
irritation.  They  bleed  if  touched  during  an  examination :  they  bleed 
during  defecation.  "  Bleeding  piles  "  is  a  term  which  is  well  applied  to 
them.  They  never  protrude  through  the  anus.  The  chief  symptom 
of  this  variety  is  hemorrhage,  which  occurs  during  every  act  of  defeca- 
tion, often  without  the  patient's  knowledge,  for  the  piles  are  painless. 
Bleeding  daily  for  weeks  or  even  months,  the  patient  becomes  anemic, 
the  heart  is  disturbed  in  its  action,  the  digestion  suffers,  and  in  females 
menstruation  ceases. 

By  natural  changes  the  arterial  hemorrhoid  merges  into  one  of  the 
other  varieties.  Constant  irritation  leads  to  inflammation  ;  inflamma- 
tion is  followed  by  thickening  of  the  adjacent  connective  tissue  ;  as  this 
increases  it  obliterates  the  capillaries  by  pressure,  and  there  is  produced 
the  second  variety — viz.  : 

The  arterial  hemorrhoid,  w^hich  is  a  freely  anastomosing  mass  of 
arteries  and  veins  bound  together  by  connective  tissue.     The  veins  are 


INJURIES    AND  DISEASES  OF  THE  DIGESTIVE   SYSTEM.         325 

varicose,  the  arteries  tortuous,  and  their  pulsations  can  be  felt  by  the 
examining  finger.  As  the  tumor  increases  in  size  it  drops  farther  and 
farther  from  the  rectum,  and  at  last  is  protruded  every  time  the  patient 
goes  to  stool.  It  is  smooth  and  firm  to  the  touch,  easily  inflamed,  and 
subject  to  erosion.  The  patient  learns  to  push  it  back  after  each  move- 
ment of  the  bowel,  and  all  goes  fairly  well  until  some  day  it  comes  out 
and  becomes  strangulated  by  the  action  of  the  sphincter  ani. 

The  venous  hemorrhoid  may  be  a  sequel  of  either  of  the  two  pre- 
ceding, or  its  venous  character  may  be  present  from  the  first.  A  vein 
beneath  the  mucous  membrane  becomes  dilated ;  inflammatory  changes 
thicken  the  membrane  and  the  connective  tissue.  A  tumor  results, 
bluish  and  hard,  which  protrudes  in  defecation,  and  is  covered  by  a 


Fig.  142. — Hemorrhoids   (from  a    photograph    in    the    collection    of  Dr.   Lincoln,  Wabasha, 

Minn.). 

mucous  membrane  which  by  gradual  thickening  from  exposure  assumes 
the  appearance  of  skin  (Fig.  142). 

All  three  varieties  may  exist  in  the  same  patient  at  the  same  time, 
each  bearing  its  own  distinctive  characteristic  or  merging  the  one  into 
the  other. 

Symptoms. — The  leading  symptom,  as  a  rule,  is  hemorrhage,  and 
in  the  capillary  variety  it  may  be  the  only  evidence.  Pain  is  not  present 
until  protrusion  takes  place  and  the  tumors  are  irritated  either  by 
friction  or  the  grasp  of  the  sphincter.  In  making  an  examination  the 
finger  should  first  be  used.  If  the  tumor  be  hard  it  will  be  readily  felt, 
but  if  soft  and  not  over-distended,  it  may  escape  detection,  even  though 
it  bleed  occasionally.  The  speculum  should  next  be  employed  and  an 
inspection  made  of  the  whole  rectal  surface.  "  An  examination  in  the 
case  of  internal  hemorrhoids  should  never  end  with  the  finding  of  a 
tumor.  An  inch  or  so  higher  up  there  may  be  stricture,  malignant  or 
simple,  which  has  given  no  sign  of  its  presence  except  the  hemorrhoids ; 
and  this  is  not  a  good  thing  to  overlook  "  (Kelsey). 


326 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


Treatment. — Tlie  palliative  treatment  is  the  same  as  in  external 
piles,  and  is  equally  unsatisfactory.  Rarely  a  spontaneous  cure  takes 
place.  The  hemorrhoids  protrude  and  become  strangulated  by  the 
action  of  the  sphincter  ani ;  ulceration  and  sloughing  follow,  causing 
the  tumor  to  drop  off,  after  which  the  part  heals  over.  The  operative 
procedures  are  as  follows : 

Revioval  by  the  Clamp  and  Cautery. — I  prefer  this  to  any  other 
incthod,  as  it  is  just  as  safe  as  the  ligature,  and  is  free  from  the  tedious 
sloughing  which  attends  the  tying  of  masses  of  tissue.  The  choice  of 
operation  should,  however,  be  determined  by  the  nature  of  the  case. 
If  the  anus  is  patulous  and  the  sphincter  relaxed,  and  especially  if  the 
hemorrhoids  are  of  the  capillary  variety,  the  treatment  by  clamp  and 
cautery  is  the  best.  The  cicatricial  contraction  which  follows  the  burns 
produced  by  the  cautery  is  here  utilized  to  remedy  the  laxity  about  the 
anus.  In  many  other  cases  such  contraction  would  prove  an  injury, 
and  in  these  cases  the  ligature  would  be  preferable. 

The  patient  should  be  prepared  for  this  or  any  of  the  other  opera- 
tions for  hemorrhoids  by  taking  a  brisk  purgative  the  previous  evening 
and  having  one  or  more  enemata  of  soap  and  water  on  the  morning  of 

the  operation.  Under  an  anesthetic  the 
sphincter  is  stretched  by  both  thumbs 
or  by  a  speculum,  and  the  tension  main- 
tained until  the  muscle  is  felt  to  give 
way.  This  gives  a  clear  view  of  the 
rectum  for  about  three  inches,  it  allows 
you  to  check  hemorrhage  should  any 
occur,  and  it  is  the  best  safeguard 
against  the  pain  which  follows  the  op- 
eration. The  lithotomy  position  is  the 
most  convenient,  the  knees  being  held 
apart  and  flexed  by  the  aid  of  a  Clover's 
crutch.  Each  of  the  tumors  brought 
down  separately  by  a  pair  of  forceps  is 
placed  within  the  blades  of  a  clamp  and 
the  instrument  tightly  screwed  up,  and 
so  placed  that  the  scar  will  radiate  from 
the  anus  as  a  centre.  The  pile  is  now 
cut  off  with  scissors  to  within  one- 
eighth  of  an  inch  of  the  clamp  (Fig. 
143).  The  Paquelin  cautery-knife  at  a 
dull  red  heat  is  applied  to  the  stump 
and  all  the  tissue  burned  away  down 
to  the  clamp.  The  instrument  is  re- 
moved and  each  remaining  pile  similarly 
dealt  with.  For  a  dressing  an  ointment 
of  iodoform  and  vaselin  is  as  good  as 
any.  The  parts  are  first  irrigated  with 
an  antiseptic,  the  ointment  spread  over 
the  cauterized  parts  and  covered  with  absorbent  cotton  held  in  place 
by  a  T-bandage.  A  morphia  suppository  or  a  hypodermic  injection 
prevents  pain  and  should  not  be  neglected.     The  bowels  are  kept  con- 


FlG.  143. — Gant's  pile-and-polypus 
clamp.  The  letters  show  the  different 
clamps  and  their  clamping  power :  A, 
Gant's;  B,  Kelsey's ;  c,  Smith's;  D, 
Langenbeck's. 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE  SYSTEM.       327 

fined  by  the  opiates  for  three  days,  after  which  a  dose  of  castor  oil  is 
given  and  the  bowels  caused  to  move  daily  thereafter.  Difficult  urina- 
tion, which  is  common  after  all  operations  on  the  rectum,  is  relieved  by 
hot  fomentations  over  the  bladder  and  by  the  use  of  the  catheter. 

Ligatuyc. — The  preparation  of  the  patient  is  the  same  us  in  the  pre- 
ceding. The  tumor  is  grasped  by  forceps  or  volsella  and  drawn  down. 
With  sharp  scissors  the  mucous  mxcmbrane  or  skin  around  the  base  of 
the  tumor  is  divided,  and  a  silk  ligature  thrown  around  the  pedicle  and 
tied  as  tightly  as  possible.  The  pile  is  cut  off  with  scissors  close  to 
the  ligature  and  the  ends  of  the  thread  cut  short.  When  the  pedicle 
is  large  it  is  best  to  transfix  it  with  a  needle  carrying  a  double  thread. 
The  muco-cutaneous  border  is  divided  as  before  and  each  half  tied  off. 

Whitehead' s  operation  is  excision  of  the  tumors,  and  is  thus  per- 
formed:  An  incision  at  the  junction  of  the  skin  and  mucous  membrane 
separates  the  membranes  from  the  muscular  tissue.  The  mucous  mem- 
brane containing  all  the  hemorrhoids  and  veins  is  dissected  off  through- 
out its  whole  circumference  and  brought  down  below  the  anal  orifice. 
On  a  line  above  the  piles  this  membrane  is  divided  transversely  and 
attached  by  a  row  of  sutures  to  the  skin  surrounding  the  anus.  The 
operation  is  very  radical,  but  is  open  to  several  objections :  It  is  more 
dangerous  than  either  ligature  or  cautery',  and  there  is  a  risk  of  stricture 
of  the  rectum  in  the  event  of  failure  of  the  wound  to  heal  by  first 
intention. 

Other  methods  which  have  been  advocated  for  the  cure  of  hemor- 
rhoids are  crushing,  injection  with  carbolic  or  chromic  acid,  ignipunc- 
ture,  dilatation  of  the  sphincter  muscle,  application  of  chemical  caustics, 
and  submucous  ligation.    But  these  cannot  be  regarded  as  trustworthy. 

Prolapsus  Ani. — This  is  a  common  accident  in  childhood  and  old 
age,  and  consists  of  a  protrusion  of  the  mucous  membrane  of  the  rec- 
tum through  the  sphincter  ani.  It  is  frequently  the  result  of  straining 
at  stool  due  to  phimosis,  constipation,  diarrhea,  or  stone  in  the  blad- 
der, and  especially  when  connected  with  a  feeble  constitution.  It  also 
occurs  in  elderly  people,  especially  those  who  have  enlarged  prostates 
and  difficult  urination.  It  frequently  complicates  pregnancy,  and  also 
hemorrhoids  and  polypi  of  the  rectum.  It  might  seem  strange  that 
errors  should  occur  in  the  diagnosis  of  prolapsus  ani,  but  such  is 
the  case. 

The  sy7)iptoms  will  depend  largely  upon  the  condition  of  the 
sphincter,  whether  or  not  there  is  constriction  of  the  protruding 
mass.  If  the  condition  has  existed  for  s^me  time  and  the  sphincter 
is  relaxed,  the  patient  will  complain  of  inconvenience  and  discomfort 
or  an  offensive  discharge  of  blood,  not  rarely  appearing  in  the  stools, 
and  pain  upon  walking  or  sitting.  Where  the  constriction  of  the  pro- 
truding mass  results  in  more  or  less  obstruction  to  the  blood-supply, 
the  symptoms  are  a  sensation  of  a  foreign  body  in  the  rectum  associated 
with  hot,  burning  pain,  a  fetid  discharge,  and  rarely  an  elevation  of  the 
body-temperature.  The  mass  may  become  ulcerated  and  sloughing, 
and  stricture  of  the  rectum  may  result.  The  gut  will  be  of  a  bright- 
red  color,  and  its  folds  can  be  easily  pressed  together  when  placed 
between  the  fingers.  Hemorrhoids  are  irregular  in  shape,  of  a  purpHsh 
or  dark-red  color,  and  when  grasped  by  the  finger  and  thumb  are  felt 


328  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

as  firm  organized  tumors.  Polypus  is  not  so  smooth  to  the  eye  and  to 
the  touch,  and  has  a  pedicle. 

Prolapsus  recti  is  a  protrusion  of  all  the  coats  of  the  rectum,  and 
is  to  be  distinguished  from  the  prolapsus  in  which  only  the  mucous 
membrane  protrudes.  The  tumor  in  prolapsed  rectum  is  usually  much 
longer  and  thicker  than  in  the  former  case.  It  may  be  several  inches 
in  length.  Cases  have  been  recorded  in  which  the  tumor  was  as  large 
as  a  fetal  head.  Symptoms  are  the  same  as  those  of  prolapsus  ani, 
greatly  intensified,  with  incontinence  of  feces. 

Trcat)>ic)it. — A  child  subject  to  prolapsus  should  be  prevented  from 
straining  at  stool.  He  should  have  an  attendant  who  will  remove  him 
from  the  commode  as  soon  as  the  bowels  are  evacuated.  When  the 
bowel  protrudes  it  should  be  wiped  with  a  soft  cloth  wrung  out  of 
cold  water,  gently  pushed  back,  and  retained  by  a  T-bandage  or  by 
broad  strips  of  adhesive  plaster  applied  so  as  to  keep  the  buttocks 
together.  I  have  found  great  benefit  from  the  use  of  astringent  injections 
given  once  a  day.     Alum,  gallic  acid,  or  hydrastis  serves  the  purpose. 

These  children  are  usually  debilitated,  and  require  iron  tonics  and 
cod-liver  oil  to  build  them  up  and  improve  their  general  health.  Con- 
stipation should  be  prevented  by  the  judicious  use  of  a  mild  laxative. 
When  the  prolapsed  bowel  remains  down  in  spite  of  the  ordinary  efforts 
of  the  nurse  or  mother  to  return  it,  the  aid  of  the  physician  is  sought. 
The  best  position  for  reduction  is  on  the  knees  and  elbows.  The  bowel, 
having  been  washed  with  cold  water,  is  anointed  with  vaselin.  The 
surgeon  then  inserts  his  finger  into  the  rectum,  and  by  taxis  practised 
around  the  finger  the  bowel  easily  slips  back  to  its  normal  position 
(Mathews). 

Sometimes  the  bowel  goes  up  more  readily  if  the  finger  is  covered 
with  a  soft  handkerchief  or  a  piece  of  lint.  Should  these  measures 
fail,  give  an  anesthetic,  w'hich,  by  quieting  the  voluntary  movements 
and  relaxing  the  sphincter,  allows  the  bowel  to  go  back  without  dif- 
ficulty. To  prevent  a  recurrence  several  operative  procedures  have 
been  recommended.  The  mucous  membrane  may  be  cauterized  in 
strips  by  solid  nitrate  of  silver  or  nitric  acid.  The  cautery  has  been  a 
favorite  remedy  with  many  surgeons,  owing  to  the  contraction  which 
follows  its  application.  It  should  be  applied  in  the  long  axis  of  the 
bowel  in  four  lines  a  quarter  of  an  inch  wide  (Cripps).  After  the 
cautery  has  been  quickly  passed  over  the  surface  in  this  manner  a  tube 
is  passed  into  the  rectum  a  distance  of  five  or  six  inches,  and  the  space 
around  it  packed  with  iodoform  and  absorbent  cotton.  The  bowels  are 
kept  quiet  by  opium  for  about  ten  days,  and  defecation  allowed  only 
while  lying  on  the  side. 

In  aggravated  cases  a  more  radical  operation  may  be  called  for,  and 
we  have  a  choice  of  several  procedures  :  {ci)  One  or  more  of  the  folds 
of  the  mucous  membrane  may  be  removed  by  the  clamp  and  cautery. 
(^)  A  V-shaped  piece  may  be  removed  from  the  sphincter  and  the 
edges  brought  together  by  sutures,  {c)  A  V-shaped  portion  is  removed 
from  the  posterior  part  of  the  sphincter  and  the  entire  thickness  of  the 
rectum,  having  a  common  base  below  (Roberts).  (^)  The  protruded 
mucous  membrane  may  be  excised  and  the  lower  edge  of  the  remainder 
attached  to  the  skin  (Treves). 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE   SYSTEM.       329 

Pruritus  Ani. — A  complication  of  many  diseases  of  the  rectum 
and  anus  is  a  very  distressing  itching.  In  some  cases  this  disagreeable 
sensation  is  constantly  present.  In  others  it  is  quiescent  during  the 
day,  but  just  as  the  patient  is  getting  warm  in  bed  and  sleep  begins  to 
steal  over  him  an  intolerable  itching  around  the  anus  begins,  and  he 
spends  a  wretched  night.  Scratching  makes  matters  ten  times  worse. 
After  enduring  this  torture  for  an  indefinite  time,  the  patient  consults 
the  physician  for  what  he  terms  "  itching  piles."  Examination  shows 
thickened,  hardened,  excoriated  skin  around  the  anus,  often  eczematous 
from  constant  irritation,  and  the  patient  can  scarcely  keep  his  fingers 
off,  so  urgent  is  the  desire  to  scratch.  Further  investigation  will  lead 
to  the  discovery  of  hemorrhoids,  prolapsus,  stricture,  or  other  rectal 
disorder.  Sometimes  the  only  apparent  derangement  is  a  mucous 
secretion  which  keeps  the  parts  moist.  Many  people  suffer  only  during 
periods  of  constipation  or  when  the  functions  of  the  hver  are  being 
imperfectly  performed,  and  in  others  the  affection  is  a  pure  neurosis. 
Alcohol  and  highly  seasoned  foods  have  been  known  to  act  as  exciting 
causes,  and  women  suffering  from  uterine  diseases  appear  to  form  a 
large  class  of  cases. 

The  itching  is  most  intense  just  inside  the  anus,  and  extends  about 
an  inch  up  the  rectum.  The  inferior  hemorrhoidal  nerve  supplies  this 
area  as  well  as  the  skin  in  the  neighborhood  of  the  anus,  which 
explains  anatomically  why  the  itching  so  uniformly  extends  over  these 
surfaces. 

Treatment. — The  treatment  of  pruritus  is  .very  unsatisfactory  and  its 
results  uncertain.  When  it  is  possible  to  ascertain  and  remove  the 
cause  this  should  be  done.  If  thread-worms  are  present,  injections  of 
the  infusion  of  quassia  should  be  employed.  Whatever  rectal  diseases 
coexist  should  receive  prompt  treatment.  For  the  relief  of  the  itching 
I  have  found  nothing  so  generally  useful  as  calomel,  either  applied  in 
powder  or  made  into  an  ointment  with  vaselin.  Inasmuch  as  the  most 
trouble  is  experienced  after  the  patient  goes  to  bed,  Mathews  recom- 
mends that  the  parts  be  bathed  in  water  as  hot  as  can  be  borne,  then 
wiped  dry  and  the  following  lotion  applied : 

3^.  Campho-phenique,  3j  ; 

Aquae  dest.,  3J. — M. 

Morain  paints  the  parts  night  and  morning  with  a  mixture  con- 
taining 60  grains  of  alum,  30  grains  of  calomel,  and  300  grains  of 
glycerol. 

To  produce  sleep  10  grains  of  sulphonal  may  be  given. 

Local  applications,  however,  will  produce  no  permanent  benefit  as 
long  as  there  is  a  thickened  and  scaly  condition  of  the  skin.  To  get 
rid  of  this  the  tincture  of  iodin  is  applied  and  renewed  in  two  or  three 
days,  or  a  solution  of  nitrate  of  silver  20  or  30  grains  to  the  ounce. 

After  the  removal  of  the  scarf  skin  local  applications  of  a  milder 
nature  can  be  used.  Some  of  the  preparations  of  tar  have  been  very 
popular,  as  the  oil  of  cade  or  marine  lint  (which  contains  tar)  placed 
between  the  buttocks  to  prevent  their  apposition.  A  lotion  containing  a 
mixture  of  menthol   and  cocain   and  an  ointment  of  oxid  of  zinc  and 


330  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

balsam  of  Peru   arc  favorite  applications.     Bulkley's  ointment  is  the 
following : 

^.  Ungt.  picis,  Siij  ; 

Untjt.  belladonnae,  Sij ; 

Tinct.  aconiti  rad.,  3ss  ; 

Zinci  oxidi,  3j ; 

Aquae  rosae,  3iij. 

After  the  disease  has  resisted  every  other  treatment  it  may  be  cured 
by  dilatation  of  the  sphincter  or  by  the  wearing  of  a  bone  plug  which 
keeps  the  anus  slightly  distended  during  the  hours  spent  in  bed. 

Inflammatory  Diseases  of  the  Rectum. — Inflammation  in  and 
about  the  rectum  not  only  produces  painful  and  troublesome  conditions, 
but  leads  to  secondary  affections.  Thus  proctitis,  or  inflammation  of 
the  mucous  membrane  of  the  rectum,  is  likely  to  end  in  ulceration, 
while  periproctitis  paves  the  way  for  fistula  in  ano. 

Proctitis  is  a  catarrhal  inflammation  of  the  mucous  membrane  of 
the  rectum,  and  is  due  to  irritation  or  infection.  Among  the  causes, 
therefore,  we  find  the  abuse  of  purgatives,  the  presence  of  foreign 
bodies  or  hardened  feces  in  the  rectum,  gonorrhea,  gout,  and  syphilis. 

The  disease  may  be  acute  or  chronic.  In  the  acute  form  the  inflam- 
mation does  not  go  deeper  than  the  mucous  membrane,  which  is 
congested  and  hyperemic.  When  the  cause  can  be  removed  this 
variety  gets  well  in  from  eight  to  fourteen  days.  In  very  exceptional 
cases,  however,  it  may  go  on  to  gangrene  of  the  bowel  and  end  in 
death.  In  the  chronic  form  the  submucous  and  muscular  layers  are 
involved,  the  bowel-wall  becomes  thickened  and  infiltrated,  and  fre- 
quently the  disease  goes  on  to  ulceration. 

Symptoms. — A  sensation  of  burning  and  heaviness  in  the  rectum  is 
a  pretty  constant  symptom.  Naturally,  this  burning  is  attended  with  a 
frequent  inclination  to  have  a  movement  of  the  bowels ;  the  action  is 
painful,  and  attended  with  tenesmus.  Neighboring  organs  sympathize  ; 
hence  there  is  pain  in  the  bladder,  and  frequent  micturition,  pain  in  the 
uterus  with  leukorrhea,  pain  in  the  sacrum,  in  the  loins,  and  along  the 
thighs.  An  examination  of  the  parts  will  show  that  the  anus  is 
inflamed,  painful,  excoriated,  and  contracted.  The  mucous  membrane 
of  the  rectum  is  intensely  congested,  and  the  temperature,  even  to  the 
examining  finger,  is  greatly  increased.  The  feces  are  streaked  with 
mucus,  blood,  and  finally  with  pus.  As  a  result  of  all  this  local  dis- 
turbance there  are  constitutional  effects,  as  fever,  nausea,  and  loss  of 
appetite.  In  chronic  proctitis  the  symptoms  are  not  so  well  marked. 
Diarrhea  may  alternate  with  periods  of  constipation.  The  pain  is  not 
so  severe  as  in  the  acute  variety.  It  is  generally  associated  with  stric- 
ture of  the  rectum.  Below  the  stricture  the  mucous  membrane  is  con- 
gested and  covered  w4th  pus  or  bloody  mucus,  while  above  it  is  eroded 
or  destroyed  (Kelsey). 

Ulceration  of  the  rectum  is  caused  by  the  irritation  of  foreign 
bodies  or  the  passage  of  hard,  scybalous  masses,  or  it  is  a  conse- 
quence of  chronic  proctitis.  Thrombosis  and  phlebitis  are  also  causes. 
The  ulceration  may  be  superficial,  simply  involving  the  epithelial  lining. 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE   SYSTEM.       33 1 

or  it  may  be  so  deep  as  to  perforate  all  the  coats  of  the  bowel.  This 
is,  of  course,  a  serious  matter,  but  much  depends  upon  the  position  of 
the  perforation.  If  it  is  low  down,  it  leads  to  abscess  and  fistula ;  if  it 
is  above  the  reflection  of  the  peritoneum,  a  fatal  peritonitis  is  a  probable 
termination. 

Syphilitic,  tubercular,  and  lupoid  ulceration  are  not  uncommon  in 
the  rectum. 

We  know  that  ulceration  of  the  bowel  higher  up,  such  as  occurs  in 
typhoid  fever,  is  attended  with  diarrhea.  The  same  symptom  attends 
ulcer  in  the  rectum.  In  the  early  and  milder  stage  the  patient  has  a 
•call  to  stool  as  soon  as  he  gets  out  of  bed.  He  passes  a  small  quantity 
of  liquid  feces  containing  mucus  like  the  white  of  an  &%^.  Once  or 
twice  in  the  forenoon  this  is  repeated.  The  rectum  is  now  empty,  and 
the  rest  of  the  day  is  spent  in  comparative  comfort.  The  condition  is 
apt  to  get  worse ;  diarrhea  increases  in  frequency  and  is  attended  with 
painful  straining ;  from  mucus  the  motions  change  to  a  dark  coffee- 
ground  material ;  the  skin  about  the  anus  is  constantly  moist,  covered 
with  vegetations  and  excrescences,  giving  rise  almost  invariably  to 
itching.  When  you  make  a  local  examination  you  find  that  if  the 
ulcer  is  about  the  anus,  it  takes  the  form  of  a  fissure,  which  is  usually 
exceedingly  tender.  If  inside  the  sphincter,  the  ulcers  lie  deep  between 
the  folds,  and  so  sensitive  are  the  parts  that  for  an  examination  with 
the  speculum  an  anesthetic  is  required.  The  finger,  however,  is  gen- 
erally sufficient,  and  it  should  be  introduced  with  the  greatest  gentle- 
ness. The  point  of  the  finger  will  meet  with  a  variety  of  conditions : 
in  one  part  are  felt  soft,  smooth  patches  with  ragged,  overhanging 
edges ;  in  another  hard  nodules  project  from  the  surface  or  dense 
bands  of  cicatricial  tissue  traverse  a  part  of  the  circumference  of  the 
bowel,  simulating  stricture.  When  the  finger  is  withdrawn  it  is  usually 
smeared  with  mucus  and  blood.  An  ulcer  due  to  syphilis  is  found  near 
the  verge  of  the  anus,  and  makes  its  appearance  during  the  first  year 
after  the  contraction  of  the  initial  lesion.  Inherited  syphilitic  ulcer 
appears  three  or  four  months  after  birth.  The  tertiary  stage  has  also 
its  rectal  ulcers  which  are  due  to  the  breaking  down  of  gummata.  The 
tubercular  ulcer  may  occur  as  a  primary  lesion  or  as  a  secondary  mani- 
festation of  tuberculosis  in  other  parts.  It  is  oval  in  shape,  its  long  axis 
corresponding  to  that  of  the  bowel ;  its  edges  are  ragged  and  under- 
mined, and  it  often  ends  in  fistula  and  abscess. 

Treatment. — Removal  of  the  cause  and  the  securing  of  perfect  rest 
are  the  first  requisites.  Injections  which  will  cleanse  and  soothe  the 
bowel  are  very  useful.  A  solution  of  chlorate  of  potash,  followed  by 
an  enema  of  starch  and  a  few  drops  of  laudanum,  gives  great  comfort 
in  the  milder  cases  of  proctitis.  A  dose  of  castor  oil  or  small  doses  of 
a  saline  aperient  should  be  given  to  remove  acrid  contents  of  the  bowel. 
The  diet  should  be  light  and  easily  digested,  and  such  articles  avoided 
as  tend  to  form  bulky  stools.  Bread,  meat,  and  vegetables  are  to  be 
avoided.  Milk,  soft-boiled  eggs,  and  prepared  foods  are  generally 
satisfactory.  In  chronic  cases  astringent  injections  of  alum,  tannin, 
nitrate  of  silver,  and  suppositories  of  iodoform  are  recommended. 

Constitutional  treatment  must  be  directed  to  the  existing  conditions. 
Syphilitic  cases  require  iodid  of  potash.     Cod-liver  oil  is  valuable,  as  it 


33^  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

not  only  tends  to  replace  the  waste  of  flesh,  but  it  keeps  the  motions 
soft. 

Operative  interference  may  be  required,  but  is  not  to  be  hastily 
adopted.  In  obstinate  cases  benefit  has  been  derived  from  stretching 
or  dividing  the  sphincter,  and  where  every  local  remedy  has  been  tried 
in  vain  colotomy  has  been  resorted  to. 

Periproctitis. — Inflammation  around  the  rectum  may  occur  in  one 
of  three  situations — close  to  the  anus  (marginal),  in  the  ischio-rectal 
fossa,  or  higher  up  about  the  insertion  of  the  levator  ani  and  the  recto- 
vesical fascia. 

1.  Margi)ial. — This  is  a  superficial  inflammation  involving  the  skin 
onh'  of  the  margin  of  the  anus.  It  is  merely  a  collection  of  pus  orig- 
inating in  one  of  the  small  glands  of  the  part,  and  may  be  caused  by 
a  traumatism  or  any  irritation,  such  as  the  pressure  of  a  rough  seat, 
the  use  of  improper  toilet-paper,  or  unhealthy  discharges  occurring  in 
menstruation,  diarrhea,  or  dysentery.  The  swelling  is  seldom  larger 
than  an  almond ;  it  rapidly  goes  on  to  the  formation  of  an  abscess 
and  opens  on  the  cutaneous  surface.  In  phthisical  persons  it  not  infre- 
quently ends  in  a  fistula.  Instead  of  appearing  at  the  cutaneous  sur- 
face, this  little  abscess  may  form  near  the  mucous  membrane,  and 
usually  it  is  the  result  of  an  inflamed  internal  hemorrhoid  at,  or  just 
inside,  the  sphincter.  It  varies  in  size  from  a  grape  to  an  almond,  and 
is  excessively  painful.  This  is  the  starting-point  of  nearly  every  blind 
internal  fistula.  After  a  few  days  of  suffering  the  abscess  bursts  into 
the  bowel,  and  the  escape  of  pus  from  the  anus  accounts  for  the  whole 
trouble. 

Treatment. — The  important  practical  point  in  all  inflammations  about 
the  rectum  is  the  danger  of  their  resulting  in  fistula.  In  order  to  pre- 
vent such  a  termination  the  abscess  should  be  opened  as  early  as  pos- 
sible and  at  right  angles  to  the  folds,  so  as  to  secure  gaping  of  the 
wound.  The  incision  should  be  kept  open  and  the  cavity  allowed  to 
heal  from  the  bottom. 

Another  form  of  superficial  abscess  occurs  in  the  subcutaneous 
tissue ;  hence  it  is  more  diffuse  and  more  difficult  to  dispose  of  than 
the  preceding.  The  diagnosis  needs  no  special  mention,  except  that 
fluctuation  is  best  elicited  by  placing  one  finger  in  the  rectum  and  the 
other  outside.     Early  and  free  incision  is  the  only  treatment. 

2.  Ischio-rectal  Abscess. — Bounded  above  by  the  levator  ani  and 
below  by  the  skin,  on  the  inside  by  the  rectum,  and  on  the  outside  by 
the  pelvis,  is  a  space  which  is  a  favorite  position  for  suppuration. 

The  most  common  cause  for  ischio-rectal  inflammation  is  trauma- 
tism. Generally  the  injury  is  from  within  the  rectum.  The  rough  use 
of  a  syringe  and  the  swallowing  of  fish-bones  or  other  sharp  objects 
figure  largely  in  the  causation.  External  to  the  rectum  the  causes  are 
kicks  and  blows,  the  pressure  of  the  fetal  head  during  parturition,  ex- 
travasation of  urine  from  ruptured  urethra,  and  necrosis  of  the  sacrum, 
the  coccyx,  or  the  lumbar  vertebrae. 

Symptoms. — The  disease  may  be  obscure  at  its  onset,  the  patient 
complaining  of  a  dull  pain  about  the  pelvis  and  loins,  with  general 
malaise,  or  the  symptoms  may  be  acute  chills,  high  temperature, 
and  severe  pain.     The  first  definite  symptom  will  probably  be  pain  in 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE   SYSTEM.       333 

defecation,  which  is  often  so  severe  as  to  amount  to  perfect  torture. 
Constitutional  symptoms  become  more  marked,  such  as  high  tempera- 
ture, rapid  pulse,  and  occasionally  chills.  On  local  examination  a  hard 
brawny  mass  is  felt  on  one  or  other  side  of  the  anus,  which  later 
becomes  red  and  fluctuating.  Sometimes  the  tendency  of  the  abscess 
is  to  burrow  upward  to  the  prostate  and  urethra,  in  which  case  there 
are  retention  of  urine  and  other  symptoms  pointing  to  prostatic  or 
urethral  complications. 

Examination  by  the  finger  or  speculum  is  generally  so  painful  as  to 
be  out  of  the  question.  If  not  opened  early,  this  abscess  is  apt  to 
burst  into  the  rectum,  forming  a  fistula.  A  chronic  form  of  the  dis- 
ease is  met  with  in  the  feeble,  debilitated,  and  phthisical. 

3.  Abscess  above  the  Levator  Ani  Muscle. — The  levator  ani  forms  a 
sling-like  support  for  the  lower  part  of  the  rectum.  It  arises  on  either 
side  from  the  posterior  surface  of  the  pubic  bone  below  the  symphysis, 
from  the  curved  white  line  indicating  the  separation  of  the  obturator 
and  recto-vesical  layers  of  the  pelvic  fascia,  and  from  the  inner  surface 
of  the  spine  of  the  ischium  (McClellan).  Passing  downward  and 
inward  toward  the  middle  line,  the  muscle  is  inserted  around  the 
rectum  between  the  internal  and  external  sphincter  ani  muscles. 

Inflammation  and  suppuration  above  this  muscle  is  a  very  serious 
matter.  The  abscess  may  assume  enormous  proportions,  blending 
laterally  with  the  subperitoneal  connectiv^e  tissue  of  the  iliac  fossa, 
and  burrowing  in  almost  any  direction  in  the  true  pelvis  (Kelsey). 
The  disease  is  generally  an  extension  from  some  of  the  neighboring 
viscera  or  the  result  of  stricture  in  the  rectum.  It  is  not  uncommon 
after  parturition  or  metritis,  the  disease  in  this  case  extending  from 
the  uterus,  thus  causing  stricture  of  the  rectum  to  be  much  more 
common  in  women  than  in  men.  In  men  the  pus  generally  burrows 
along  the  side  of  the  bowel,  making  its  way  into  the  ischio-rectal 
fossa,  and  finally  through  the  skin  of  the  perineum  at  some  distance 
from  the  anus.  In  females  it  not  unfrequently  burrows  upward,  reach- 
ing the  skin  about  the  crest  of  the  ileum  or  in  the  groin.  Not  unfre- 
quently the  abscess  ruptures  into  the  rectum.  We  then  have  a  charac- 
teristic symptom.  Pus  is  discharged  at  each  act  of  defecation.  If  the 
opening  is  near  the  anus,  the  pus  comes  before  the  feces  ;  if  it  is  above 
the  rectal  pouch,  it  comes  after  the  feces. 

In  very  exceptional  cases  the  abscess  ruptures  into  the  bladder,  the 
uterus,  the  peritoneum,  or  the  vagina. 

Treatvioit. — Early  incision  is  here  the  only  proper  course.  As  soon 
as  diagnosis  of  the  existence  of  pus  is  made,  even  before  fluctuation  is 
detected,  the  patient  should  be  anesthetized  and  the  abscess  freely  and 
deeply  incised.  All  pockets  should  be  explored,  thoroughly  evacuated, 
and  made  to  communicate  freely  with  the  main  cavity.  This  should 
then  be  well  irrigated  with  a  i  :  2000  sublimate  solution,  dusted  with 
iodoform,  and  packed  loosely  with  iodoform  gauze.  A  drainage-tube 
should  be  inserted  and  the  cavity  made  to  granulate  from  the  bottom. 

Fistula  in  Ano. — Any  of  the  forms  of  abscess  just  mentioned  may 
heal  to  a  certain  point  and  then  remain  stationary,  keeping  up  a  con- 
stant discharge  of  pus  by  an  opening  into  the  rectum  or  externally 
through  the  skin,  or  in  both  directions.    When  the  fistula  has  an  open- 


334 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


ing  through  both  skin  and  rectum,  it  is  called  complete;  when  the  open- 
ing is  in  only  one  direction,  it  is  termed  incomplete  or  blind.  A  fistula 
whose  only  opening  is  into  the  rectum  is  a  blind  internal  fistula,  and 
one  opening  only  through  the  skin  is  a  blind  external  fistula. 

Fistuke  may  be  divided  into  anal  and  rectal.  In  the  first  class  the 
opening  is  close  to  the  anus,  almost  entirely  subcutaneous  or  penetrat- 
ing some  of  the  lower  fibers  of  the  sphincter.  They  are  generally  the 
sequelae  of  marginal  abscesses.  Rectal  fistulae  are  deeper,  traversing 
the  ischio-rectal  fossa  and  passing  into  the  bowel  between  the  external 
and  internal  sphincter  or  even  above  the  internal.  Sometimes  there 
are  numerous  fistulous  channels  running  in  different  directions  until 
the  perineum  is  fairly  riddled  by  them  (Fig.  144).     Pus  burrowing  in 


Fig.  144. — Horseshoe  fistula  with  multiple  openings  (Gant). 

the  loose  tissues  of  the  perineum  may  travel  far,  and  thus  the  external 
opening  is  often  found  at  a  considerable  distance  from  the  anus.  Some 
cases  have  been  recorded  in  which  the  opening  was  in  the  groin,  others 
in  which  pus  burrowed  beneath  the  gluteal  muscles  and  opened  in  the 
thigh  and  even  the  popliteal  space.  The  walls  of  the  fistula  are  gen- 
erally thickened  by  increase  of  fibrous  tissue,  the  result  of  chronic 
inflammation ;  the  surface  is  covered  w^ith  granulations  which  secrete  a 
thin  purulent  fluid.  The  external  opening  is  generally  small,  scarcely 
admitting  a  probe,  and  sometimes  surrounded  by  a  mass  of  granula- 
tions. The  course  of  the  channel  may  be  direct  from  the  skin  to  the 
rectum,  and  the  point  in  the  rectum  which  is  the  seat  of  the  opening 
is  about  an  inch  from  the  anus  or  between  the  internal  and  external 
sphincter.  Sometimes  the  sinus  runs  partly  around  the  rectum,  giving 
what  is  called  a  horseshoe  fistula. 

Symptoms. — The  early  histor}^  of  a  fistula  is  the  history  of  the 
abscess  which  produced  it.  Generally  the  patient  seeks  advice  long 
after  the  abscess  has  discharged.  He  expects  the  opening  to  heal,  and, 
as  it  gives  no  trouble  beyond  a  daily  discharge  of  pus  and  serum,  he 
bears  the  inconvenience   until  the  opening  closes  temporarily  and  a 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE   SYSTEM.       335 

new  collection  of  pus  takes  place.  The  skin  at  such  a  time  becomes 
red  and  tender,  movement  of  the  bowels  causes  great  pain,  and  the 
symptoms  of  abscess  are  repeated  until  discharge  of  pus  takes  place, 
either  by  the  old  or  through  a  new  opening.  In  the  ordinary  condi- 
tion of  the  fistula  the  skin  about  the  part  is  always  moist,  sometimes 
eczematous  or  covered  with  small  boils.  In  the  subcutaneous  tissues 
fistulous  tracts  can  always  be  detected  by  their  hard,  resistant  feel. 

From  the  opening  escapes  a  thin  purulent  fluid,  always  offensive  in 
smell ;  when  the  opening  is  large  enough,  gas  and  even  feces  escape. 
These  are  positive  signs  of  fistula,  but  the  variety  of  fistula  must  be 
determined  by  further  examination.  Place  the  patient  on  the  affected 
side  with  the  knees  drawn  up.  The  external  opening  is  generally  easily 
found,  but  sometimes  it  is  concealed  between  the  folds  of  skin  or  it  may 
be  temporarily  closed.  Even  then  its  position  can  often  be  determined 
by  the  induration  and  thickening  of  the  tissues  at  that  point.  Having 
found  the  external  opening,  a  probe  is  inserted  and  gently  pushed 
toward  the  opening  in  the  rectum.  Here  let  me  warn  you  against 
two  common  errors :  Do  not  look  for  the  internal  opening  too  high 
up.  It  is  generally  between  the  internal  and  external  sphincter.  Do 
not  pass  the  finger  into  the  rectum  until  you  have  pushed  the  probe  as 
far  as  it  will  go.  The  presence  of  the  examining  finger  causes  the 
sphincter  to  contract  violently,  which  changes  the  relation  of  the  fistu- 
lous track  and  prevents  the  probe  passing  through  it.  Insert  the  finger 
after  the  probe  has  passed  as  far  as  it  will  go.  If  the  course  is  moder- 
ately straight,  the  examining  finger  will  find  the  point  of  the  probe  in 
the  rectum.  If  the  probe  has  not  passed  through  the  internal  opening, 
the  finger  must  search  for  it.  No  matter  how  many  external  openings 
exist,  there  is  only  one  internal.  The  finger  can  generally  detect  it 
even  if  the  probe  does  not  go  through.  In  some  cases  the  end  of  the 
probe  can  be  felt  with  only  a  thin  portion  of  the  mucous  membrane 
between  it  and  the  finger.  This  is  sufficient.  Push  the  probe  through 
this  thin  spot. 

A  valuable  aid  to  diagnosis  which  I  have  never  found  to  fail  is  the 
injection  of  peroxid  of  hydrogen.  A  speculum  is  introduced,  the  per- 
oxid  injected  by  the  external  opening,  and  its  appearance  watched  for 
at  the  internal  opening.  If  a  fistula  be  present,  the  froth  caused  by 
the  peroxid  will  be  seen  to  ooze  through  the  internal  opening,  and  in  a 
short  time  it  almost  fills  the  rectum. 

A  diagnosis  of  the  fistula  and  the  kind  of  fistula  is  not  sufficient. 
A  very  important  practical  point  remains  to  be  settled :  Is  there  a 
stricture  of  the  rectum  ?  Sometimes  stricture  and  fistula  coexist,  the 
stricture  being  high  up  and  the  fistula  near  the  anus.  To  operate  on 
the  fistula  and  overlook  the  stricture  would  be  a  bungling  piece  of 
work.  Again,  the  abscess  which  led  to  the  formation  of  the  fistula 
may  have  been  due  to  necrosis  of  the  sacrum,  coccyx,  or  vertebrae. 
An  operation  dealing  only  with  the  fistula  would  be  worse  than  useless. 

Blind  internal  fistulae  have  generally  large  openings,  and  it  is 
not  uncommon  to  find  that  feces  enter  this  cloaca  viaxhna  and  keep 
up  irritation  which  prevents  healing  for  an  indefinite  time.  These 
fistulae  are  generally  painful,  not  only  during  defecation,  but  when 
pressure  is  made  externally  near  the  anus.     Diagnosis  of  this  variety 


336 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


is  made  by  fcelin<:;^  the  internal  opening  and  by  passin<^  a  bent  probe 
through  the  anus  and  into  the  fistula. 

Treatment. — Palliative  treatment  is  of  little  or  no  avail  in  fistula. 
A  free  incision  conv^erting  the  fistulous  track  into  an  open  wound,  which 
is  allowed  to  heal  from  the  bottom,  is  the  most  satisfactory  treatment. 
An  aperient  is  given  the  night  before,  and  an  enema  of  soap  and  water 
on  the  morning  of  the  operation.  The  patient  is  anesthetized,  and 
placed  either  in  the  lithotomy  position  or  on  his  side  with  the  limbs 
well  drawn  up.  A  grooved  director  is  passed  by  the  external  opening 
through  the  fistula  and  out  at  the  anus,  and  then  a  curved  knife  is 
made  to  run  along  the  groove  (Fig.  145),  dividing  all  the  tissues,  cut- 


FlG.  145. — Typical  case  of  fistula  in  ano,  with  operation  for  the  same  (Gant). 


ting  the  fibers  of  the  sphincter  as  nearly  at  right  angles  as  possible. 
The  track  of  the  fistula  should  then  be  scraped  with  a  Volkmann's 
spoon  to  remove  all  granulation-tissue.  A  packing  of  iodoform  gauze 
and  a  pad  of  sterilized  gauze  and  absorbent  cotton  held  in  position 
with  a  T-bandage  complete  the  operation.  The  bowels  should  be  kept 
confined  for  two  days  and  the  wound  repacked  daily  with  great  care. 

In  horseshoe  fistula  the  incision  on  one  side  should  be  made  in  the 
usual  manner,  while  the  opposite  sinus  should  be  freely  dilated  and 
drained.  To  open  up  both  fistulae  would  necessitate  division  of  the 
sphincter  in  two  places.  This  will  almost  to  a  certainty  be  followed  by 
incontinence. 

Goodsall  recommends  the  following  method  of  operating  on  horse- 
shoe fistula :  First  pass  a  probe-pointed  director  through  the  internal 
aperture,  and  on  its  point  incise  the  skin  in  the  middle  line  behind ; 
then  push  the  director  through,  and  slit  up.  Second,  slit  up  the  lateral 
sinuses  on  directors  passed  in  at  the  external  openings  and  brought  out 
at  the  external  incision.  When  numerous  external  openings  exist  it 
may  be  necessary  to  open  up  several  of  the  sinuses  and  leave  others 
for  a  second  operation.  A  tortuous  fistula,  instead  of  being  cut  through 
at  once,  should  be  dissected  up  on  a  director  from  the  external  opening. 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE  SYSTEM.        337 

Sinuses  which  are  offsets  from  the  main  fistula  can  be  followed  up  in 
the  same  manner.  The  walls  of  the  sinus  should  be  dissected  out  and 
the  wound  packed  with  iodoform  gauze.  Closing  the  wound  by  su- 
tures with  the  view  of  obtaining  primary  union  is  sometimes  successful, 
but  I  have  known  cases  in  which  this  plan  was  attempted  with  very 
unsatisfactory  results.  The  fistulous  tracks  retained  suppurating  mate- 
rial and  necessitated  operations  at  a  later  period. 

Fistula  in  phthisical  subjects  should  be  operated  upon  under  certain 
restrictions.  A  cough  which  is  violent  and  frequent  is  a  contra- 
indication, as  it  prevents  healing  of  the  incision.  In  rapidly  advancing 
lung  disease,  in  persistent  diarrhea,  or  in  an  advanced  stage  of  tuber- 
culosis in  any  organ  it  is  not  advisable  to  operate.  In  ordinary  cases 
of  phthisis  complicated  with  fistula  improvement  may  be  expected  after 
treatment  of  the  fistula,  for,  although  the  pulmonary  disease  may 
render  the  condition  of  the  patient  hopeless,  he  is  saved  the  misery 
of  a  very  exhausting  complication. 

Other  methods  of  treating  fistula  have  been  advocated  from  time  to 
time.  Injections  of  iodin  and  of  nitrate  of  silver  have  been  known  to 
cure,  so  also  has  dilatation  of  the  mouth  of  the  sinus,  but  the  effect  of 
such  remedies  is  so  uncertain  that  they  scarcely  deserve  mention.  The 
elastic  ligature  is  employed  in  patients  who  are  strongly  opposed  to 
the  use  of  the  knife.  It  is  also  recommended  in  a  fistula  whose  inter- 
nal opening  is  high  up  in  the  rectum.  In  every  other  case  it  is  far 
inferior  to  incision.  The  ligature  when  employed  should  be  of  solid 
rubber  about  one-tenth  of  an  inch  in  diameter.  It  is  passed  through 
the  fistula  and  out  the  anus,  then  tightly  secured  by  means  of  a  lead 
clamp. 

Fissure  of  the  Anus. — A  fissure  or  small  ulcer  at  the  anal 
orifice,  attended  with  the  most  excruciating  pain,  and  producing  symp- 


FlG.  146. — Painful  ulcer  (fissure)  of  the  anus  (Gant). 

toms  out  of  all  proportion  to  the  extent  of  diseased  tissue,  has  been  spe- 
cialh'  named  anal  fissure  or  irritable  ulcer  (Fig.  146).  Its  commonest 
situation  is  on  the  posterior  wall  of  the  rectum  about  the  junction  of 
the  skin  with  the  mucous  membrane.  It  is  not  uncommon  to  find  it 
lying  under  a  small  hemorrhoid,  presenting  the  appearance  of  a  little 
fissure  lying  between  two  folds  of  muco-cutaneous  tissue.  If,  however, 
22 


338  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

the  folds  be  separated  and  the  anus  dilated,  the  shape  changes  to  a 
round   or  oval  ulcer. 

After  all,  there  is  nothing  special  about  this  form  of  ulcer,  for  it  can 
be  caused  by  anything  which  causes  an  abrasion  or  laceration  of  the 
tissue  at  the  anal  orifice.  Its  position  gives  it  two  characteristics  which, 
kept  in  mind,  make  it  easy  to  understand  the  disease  :  It  is  exceedingly 
painful,  and  therefore  well  named  irritable  ulcer.  This  is  the  first  cha- 
racteristic. The  junction  of  skin  and  mucous  membrane  is  always  a 
highly  sensitive  line.  An  ulcer  of  the  mucous  membrane  alone,  how- 
ever slightly  removed  from  this  line,  is  not  nearly  as  painful.  The 
extreme  sensitiveness  of  the  ulcer  causes  reflex  contraction  of  the 
sphincter  ani  muscle,  which  is  the  second  characteristic. 

Symptoms. — There  is  nothing  that  can  compare  with  a  severe  case 
of  anal  fissure.  The  patient  at  stool  experiences  a  pain  which  he 
believes  is  tearing  his  anus  or  burning  the  part  as  with  a  red-hot  iron. 
He  is  thrown  into  a  state  of  collapse ;  the  pulse  becomes  feeble,  the 
surface  of  the  body  is  damp  and  cold,  and  beads  of  perspiration  break 
out  on  the  forehead.  For  hours  this  may  continue,  and  the  sufferer 
naturally  dreads  to  have  a  movement  of  the  bowels,  and  they  are 
allowed  to  become  constipated.  This  only  increases  the  suffering  by 
hardening  the  feces  and  making  defecation  more  painful  than  ever. 
Blood  to  the  extent  of  a  drop  or  two  is  sometimes  seen  on  the  motions. 
Retention  of  urine  is  common  in  men,  and  menstrual  disorders  in 
women.  The  sphincter  is  rigidly  contracted  and  feels  hard  to  the 
touch.  Digital  examination  is  out  of  the  question  without  an  anes- 
thetic. An  inspection  shows  a  fissure,  usually  on  the  posterior  wall, 
and  taking  a  round  or  oval  form  when  the  anus  is  dilated.  The  surface 
is  covered  wdth  red,  inflamed  granulations  or  a  thin  slough.  In  these 
red  granulations  are  the  exposed  nerve-filaments  to  which  are  due  the 
extreme  sensibility.  Hemorrhoids,  blind  internal  fistula,  and  sphincter- 
ismus might  be  mistaken  for  ulcer. 

Treatment. — In  mild  cases  healing  of  the  ulcer  may  be  secured  by 
astringent  ointments,  the  application  of  weak  solutions  of  nitrate  of 
silver  or  sulphate  of  zinc,  and  by  keeping  the  bowels  in  a  relaxed  con- 
dition. In  more  severe  and  obstinate  cases  the  patient  may  be  given  an 
anesthetic,  and  the  ulcer  then  freely  cauterized  with  nitrate  of  silver  or 
the  acid  nitrate  of  mercury'.  The  bowels  are  kept  from  acting  for  a 
day  or  two,  and  the  patient  keeps  his  bed  until  the  ulcer  heals. 

The  most  obstinate  cases  are  those  in  which  the  sphincter  is  hyper- 
trophied  from  constant  contraction,  and  these  require  a  more  radical 
method  of  treatment.  To  overcome  the  action  of  the  muscle  its 
superficial  fibers  can  be  divided  or  it  can  be  fully  stretched.  The 
patient  is  placed  under  chloroform  ;  the  sphincter  is  then  stretched  with 
the  thumbs,  and  the  floor  of  the  ulcer  divided  with  a  knife  down  to  the 
extent  of  a  quarter  of  an  inch,  which  is  sufficient  to  sever  the  super- 
ficial fibers  of  the  sphincter.  The  base  of  the  ulcer  should  be  dissected 
out  and  the  wound  packed  with  iodoform  gauze.  At  the  same  time, 
any  small  hemorrhoid,  polypus,  or  tag  of  skin  should  be  removed ;  a 
sinus,  if  present,  should  be  opened  up,  the  upper  region  of  the  rectum 
examined,  and  in  the  case  of  females  any  retroversion  of  the  uterus 
corrected. 


INJURIES  AND  DISEASES   OF   THE   DIGESTIVE  SYSTEM.       339 

Spasm  of  the  Sphincter  (Sphincterismus). — This  is  an  affec- 
tion which  is  most  commonly  seen  in  fissure  of  the  anus,  but  it  also 
exists  in  hysterical  women,  and  in  persons  suffering  from  diseases  of 
neighboring  organs,  as  the  uterus  or  bladder.  In  some  cases  there  is 
an  undiscoverable  cause.  When  due  to  fissure  this  latter  condition 
should  be  attended  to ;  in  hysterical  women  a  suppository  containing 
two  grains  of  the  extract  of  belladonna  is  very  efficient,  and  in  obsti- 
nate cases  from  any  cause,  stretching  the  sphincter  is  an  almost  certain 
cure. 

Tumors  of  the  Rectum. — Of  the  benign  growths  the  most 
common  in  the  rectum  is  polypus.  The  term  polypus,  however,  is 
applied  to  any  growth  projecting  from  the  mucous  membrane  into  the 
cavity  of  the  bowel.  Sometimes  it  is  an  hypertrophy  of  the  mucous 
membrane,  sometimes  a  fibroma  or  an  adenoma  (Fig.  147),  sometimes 


Fig.  147. — Fibrous  (hard)  polypus  (Gant). 


a  villous  growth.  Polypi  are  generally  single,  occurring  frequently  in 
children  below  nine  years  of  age.  They  are  usually  attached  to  the 
posterior  surface  of  the  rectum  and  not  far  from  the  anus.  In  size 
they  seldom  reach  the  dimensions  of  a  walnut,  but  they  have  been 
found  in  such  numbers  as  to  block  up  the  bowel  and  produce  symptoms 
of  intestinal  obstruction. 

Symptoms. — When  a  child  has  hemorrhage  from  the  rectum  polypi 
should  always  be  suspected.  Just  as  in  uterine  polypus,  hemorrhage 
is  a  pretty  constant  symptom.  A  digital  examination  of  the  rectum 
should  always  be  made  in  such  cases,  when,  if  a  polypus  be  present, 
it  will  be  felt  hanging  from  the  rectal  wall,  usually  the  posterior  sur- 
face. When  the  pedicle  is  long,  however,  it  may  be  directed  upward, 
so  that  the  tumor  is  out  of  reach.  On  this  account  an  enema  of  warm 
water  should  be  given  before  the  examination.  The  expulsion  of  the 
fluid  brings  down  the  polypus  to  the  full  length  of  its  pedicle  (Fig.  148). 
The  length  of  the  pedicle  varies  greatly.  In  some  cases  it  is  so  long 
that  the  tumor  escapes  through  the  anus  during  defecation,  and  it  not 
infrequently  happens  that  the  sphincter,  contracting  firmly  on  the 
pedicle,  strangulates  the  growth  and  causes  it  to  drop  off,  thus  effecting 
a  spontaneous  cure. 

The  diagnosis  of  polypus  with  a  long  pedicle  is  very  simple.  It  is  a 
very  different  matter  when  the  attachment  of  the  tumor  is  broad  and 


340 


SURGICAL    DIAGNOSIS  AND    TREATMENT. 


the  pedicle  absent.     The  question  then  arises  as  to  whether  the  tumor 
is  benign  or  maUgnant.    Diagnosis  must  rest  upon  the  following  points  : 

1.  In  children  malignant  disease  is  exceedingly  rare,  while  polypi 
are  frequently  met  with. 

2.  Malignant  tumors  are  not  extruded  and  are  not  pedunculated,  so 
that  the  existence  of  even  a  very  short  pedicle  is  strong  evidence  of 
polypi. 

In  adults  an  adenoid  polypus  which  has  ulcerated  and  which  is  not 
pedunculated  cannot  always  be  distinguished  from  malignant  disease,. 


Fig.  148. — Adenoid  (soft)  polypus  (Gant). 


either  by  the  microscope  or  the  clinical  history ;  for  the  ulcerated  and 
bleeding  tumor  may  cause  a  wasting  and  cachexia  which  strongly 
resemble  cancer  (Kelsey). 

Treatment. — The  treatment  of  polypi  is  very  simple  when  the  tumor 
is  pedunculated.  Hemorrhage  is  the  only  danger,  and  this  can  be 
obviated  by  first  throwing  a  ligature  around  the  pedicle  and  then 
dividing  the  tissue  with  scissors  close  to  the  point  of  ligation.  Some- 
times the  pedicle  is  so  long  and  slender  that  the  tumor  can  be  twisted 
off  by  grasping  it  with  forceps  and  making  simple  torsion.  When 
polypi  have  no  pedicles,  they  must  be  removed  in  the  same  manner  as 
ordinary  tumors,  and  the  bleeding  stopped  by  forceps  and  by  packings 
with  gauze  or  sponges  wrung  out  of  hot  water.  Removal  of  polypi 
by  clamp  and  cautery  is  advocated  by  some  authors. 

Papillomata,  Warts,  or  Vegetations. — These  warty  growths 
occur  about  the  anus  in  persons  who  are  the  subjects  of  warts  in  other 
parts  of  their  bodies.  Their  development  is  favored  by  the  presence 
of  any  irritating  discharge,  such  as  occurs  in  gonorrhea,  leukorrhea,^ 
or  any  disease  of  the  rectum.  Formerly  these  growths  were  held  in 
very  bad  repute,  being  considered  positive  evidence  not  only  of  syphilis 
but  of  sodomy.  Molliere  relates  how  in  the  time  of  Dionysius  there 
was  a  hospital  in  Rome  for  the  treatment  of  these  growths  ;  the  sur- 
geons, according  to  Dionysius,  spared  neither  the  iron  nor  the  fire,  and 
were  not  moved  to  pity  by  the  cries  of  the  patients,  inasmuch  as  this 
disease  was  the  result  of  unnatural  intercourse  between  man  and  man 
(Molliere,  quoted  by  Kelsey).  The  ideas  of  surgeons  have  undergone 
considerable  change  in  recent  years,  the  cause  now  being  considered  to 
be  a  tendency  to  warts,  plus  a  local  irritation. 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE   SYSTEM.        34 1 

Symptojjis. — While  papillomata  occur  at  almost  any  age,  they  are 
most  frequently  found  in  adults.  The  appearance  will  vary  according 
to  the  number  of  warts.  When  occurring  singly  the  surface  is  dry ; 
when  existing  in  numbers  they  secrete  a  fluid  of  very  disagreeable 
odor.  This  secretion  is  irritating,  and  not  only  causes  inflammation 
in  the  warts  themselves,  but  in  the  surrounding  skin.  When  the 
growth  begins  on  one  side  of  the  intergluteal  fold,  the  pressure  of 
their  moistened  surface  against  the  opposite  side  produces  a  second 
growth  at  that  point.  The  patient  suffers  great  discomfort  from  the 
odor  and  irritation,  and  not  infrequently  defecation  is  attended  with 
considerable  pain.  Little  difficulty  is  experienced  in  the  diagnosis  of 
these  growths ;  the  most  common  error  arises  by  mistaking  them  for 
syphilitic  condylomata  or  for  mucous  patches.  The  surface  of  a  flat 
condyloma  or  mucous  patch  is  smooth  and  different  from  the  cauli- 
flower-like growth  of  a  papilloma.  The  papilloma,  moreover,  is  found 
to  be  attached  to  the  skin  by  a  number  of  small  pedicles,  so  that  if  the 
whole  growth  be  cut  off  at  the  level  of  the  skin,  it  does  not  leave  a  raw 
surface,  but  a  number  of  minute  bleeding  points. 

Treatment. — Excision  with  knife  or  scissors  is  the  best  and  most 
rapid  treatment.  Applications  of  strong  astringents,  such  as  tannin  or 
alum  or  strong  acetic  acid,  are  sometimes  sufficient  to  remove  them. 

Condylomata. — This  is  a  term  applied  to  several  different  growths 
about  the  anus,  as  the  raised  mucous  patches  and  the  remains  of  exter- 
nal hemorrhoids.  There  is  a  growth  known  as  condyloma  which  is 
non-syphilitic.  It  is  attached  by  a  broad  base,  is  of  a  pink  color,  soft, 
fleshy,  moist,  and  flattened  where  two  are  pressed  together.  Condy- 
lomata generally  begin  at  a  fold  of  the  anus  (Kelsey).  They  are  due 
to  a  localized  chronic  inflammation  of  the  skin.  They  are  most  likely 
to  be  confounded  with  syphilitic  gummata. 

Syphilitic  condylomata  begin  as  red  spots  with  slight  effusion 
beneath  the  epidermis.  The  thin  covering  formed  by  the  epidermis  is 
rubbed  off,  and  a  raw  surface  is  left  covered  with  a  thin  pellicle.  Upon 
this  surface  a  new  growth  takes  place,  composed  of  papillae,  connective 
tissue,  and  blood-vessels.  In  this  respect  it  closely  resembles  the  papil- 
lomata, and  in  fact  their  appearance  is  sometimes  identical.  Diagnosis 
must  rest,  therefore,  upon  the  history,  the  mode  of  development,  and 
the  results  of  treatment. 

Fibromata,  lipomata,  villous  growths,  enchondromata,  and  sarcomata 
are  so  rare  as  to  need  no  special  mention. 

(For  cancer  of  the  rectum  see  Cancer  of  the  Intestines.) 

Stricture  of  the  Rectum. — Stricture  of  the  rectum  may  be  due 
to  changes  in  the  bowel-wall  which  lessen  its  caliber,  or  to  pressure 
from  without.  Tumors  in  the  pelvis  by  gradual  encroachment  on  the 
rectum  may  cause  a  diminution  of  its  caliber,  but  this  is  generally  an 
obstruction  rather  than  a  stricture. 

Two  classes  of  stricture  are  recognized — simple  and  malignant. 
The  latter  has  been  discussed  in  the  section  on  Rectal  Cancer.  Simple 
stricture  is  generally  associated  with  inflammation,  and,  bearing  this  in 
mind,  its  etiology  is  readily  understood.  Inflammation,  and  especially 
the  chronic  form,  tends  to  increase  the  connective  tissue  of  the  part 
affected.     The  connective  tissue  of  the  rectum  is  arranged  in  a  circular 


342 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


manner  around  the  bowel,  so  that  inflammation  by  increasing  this 
fibrous  tissue  causes  a  constriction.  We  have,  therefore,  the  following 
among  the  causes  of  simple  stricture : 

1.  Traumatism,  such  as  kicks,  blows,  the  application  of  strong 
acids,  operations  on  the  rectum,  ulceration,  and  the  presence  of  foreign 
bodies.     All  of  these  produce  stricture  close  to  the  orifice  of  the  anus. 

2.  When  the  stricture  is  higher  up  the  principal  causes  are — ope- 
rations for  internal  hemorrhoids,  tuberculosis,  syphilis,  dysentery, 
parturition,  pelvic  cellulitis,  and  imperforate  rectum,  partial  or  complete. 

Strictures  arising  from  any  of  these  causes  may  affect  a  small  or  a 
large  portion  of  the  rectum,  and  two  varieties  are  spoken  of  according 
to  the  extent  of  the  stricture.  If  it  involves  an  inch  or  less,  the  stric- 
ture is  called  anmtlar  (Fig.  149);  if  more  than  an  inch,  it  is  tubular 
(Fig.   150). 


Fig.  149. — Diagrammatic  drawing 
of  annular  stricture  (Gant). 


Fig.  150. — Diagrammatic  drawing  of 
tubular  stricture  (Gant). 


Syviptoms. — Of  seven  patients  suffering  from  stricture  of  the  rectum, 
six  are  women.  Common  sense  tells  us  that  the  leading  symptoms  are 
obstruction,  due  to  narrowing  of  the  bowel  and  irritation  and  inflam- 
mation which  produce  the  stricture.  When  high  up  obstruction  may 
be  an  early  symptom,  and  may  appear  with  very  slight  warning.  In 
stricture  low  down  it  does  not  appear  until  a  late  period.  The  first 
symptom  is  generally  a  diarrhea  coming  on  when  the  patient  gets  out 
of  bed  and  after  each  meal.  The  motions  are  either  small  like  pellets, 
or  ribbon-shaped  and  covered  with  mucus.  Later  on,  constipation 
alternates  with  diarrhea.  Pain  becomes  a  prominent  symptom,  felt 
especially  in  the  perineum  and  radiating  to  the  hips  and  down  the 
thighs.  The  sphincter  loses  its  tonicity,  becomes  flabby,  and,  later  on, 
raw  and  excoriated.  There  is  a  constant  offensive  discharge  about  the 
anus  which  keeps  the  parts  moist  and  irritated.  Later  on,  obstruction 
becomes  more  apparent.  In  some  cases  the  transverse  and  descending 
colon  can  be  felt  distended  with  feces,  dull  on  percussion,  sensitive  to 
touch,  and  retaining  indentations  made  by  pressure  of  the  fingers.  The 
bowels  are  never  properly  emptied ;  abscesses,  fistulae,  and  ulceration 


INJURIES  AND  DISEASES   OF  THE  DIGESTIVE   SYSTEM.       343 

are  common ;  and  at  last  the  patient  dies  either  of  peritonitis, 
the  result  of  complete  obstruction,  or  wastes  away  from  sheer  ex- 
haustion. 

No  diagnosis  is  complete  without  a  local  examination,  which  can  be 
digital  or  by  bougies.  The  finger  is  preferable.  A  constriction,  ring- 
shaped  or  tubular,  is  felt,  which  at  once  settles  the  question.  Should  the 
stricture  be  too  tight  to  allow  the  finger  to  pass  through,  no  attempt 
should  be  made  to  force  it.  Death  has  occurred  more  than  once 
by  rough  examination.  Having  satisfied  yourself  that  a  stricture 
exists,  examine  the  condition  of  the  rectum  below  the  narrowing. 
In  females  the  vaginal  examination  may  throw  considerable  light  on 
the  subject. 

No  end  of  mistakes  have  been  made  by  depending  upon  bougies. 
Many  supposed  strictures  have  proved  to  be  nothing  more  than  the 
arrest  of  the  instrument  by  the  promontory  of  the  sacrum.  When  the 
stricture  appears  to  be  beyond  the  reach  of  the  finger,  something  can 
be  gained  by  having  an  assistant  press  the  elbow  of  the  examining  arm, 
thus  pushing  the  perineum  well  up.  Olive-pointed  bougies  or  long 
rectal  tubes  are  sometimes  useful. 

Stricture  high  up  in  the  rectum  or  in  the  sigmoid  flexure  is  very 
difficult  of  diagnosis.  The  symptoms  complained  of  by  the  patient 
are  different  from  those  already  described.  Chronic  constipation  and 
dyspepsia  are  the  most  prominent.  Pain  is  felt  in  the  abdomen, 
generally,  but  not  always,  in  the  left  side ;  sometimes  in  the  loins 
and  down  the  thighs.  An  examination  of  the  feces  gives  nothing 
satisfactory.  The  motions,  being  formed  in  the  rectum,  have  not  the 
ribbon  or  pellet-shape  characteristic  of  a  stricture  low  down.  The 
most  significant  appearance  is  the  presence  of  blood  or  slime  in 
streaks  in  the  feces.  When  the  constriction  is  due  to  a  morbid  growth, 
palpation,  inspection,  and  percussion  of  the  abdomen  may  afford  valu- 
able evidence. 

In  making  a  diagnosis  of  high  stricture  I  would  recommend  the 
following  procedures  : 

1.  Obtain  a  history  of  the  subjective  symptoms,  such  as  constipation, 
diarrhea,  pain  in  the  left  side  of  the  abdomen,  loins,  and  thighs. 

2.  An  examination  of  the  feces  for  streaks  of  blood  or  slime. 

3.  Inspection,  palpation,  and  percussion  of  the  abdomen  for  tumor 
or  fecal  impaction  in  the  colon. 

4.  Examination  with  the  finger  under  anesthesia,  aided  by  an  assist- 
ant pushing  against  the  examiner's  elbow  to  raise  the  perineum. 

5.  The  insertion  of  bougies.  The  best  instrument  is  hollow,  and  to 
its  lower  end  should  be  fitted  the  tubes  of  a  fountain  syringe  or  irri- 
gator containing  warm  sterilized  Avater.  The  bougie  must  be  inserted 
with  the  greatest  gentleness,  and  as  soon  as  resistance  is  felt  the  water 
should  be  allowed  to  flow  and  distend  that  portion  of  the  bowel.  This 
will  dispose  of  folds  of  mucous  membrane  which  are  so  ready  to  obstruct 
the  tube.  In  order  to  pass  the  promontory  of  the  sacrum  the  bougie 
requires  to  be  flexible. 

6.  Failing  in  making  a  diagnosis  by  any  of  the  preceding,  the  hand 
may  be  pressed  into  the  rectum  under  the  restrictions  already  men- 
tioned. 


344  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

Differential  Diagnosis  of  Benign  and  Malignant  Strictnrc  (Ball). 
Benign.  Malignant. 

Generally  a  disease  of  adult  life.  Generally  a  disease  of  old  age. 

Essentially  chronic,  and  not  implicating  the     Progress   comparatively   rapid,    and    general 

system  for  a  long  time.  cachexia  soon  produced. 

The  orifice  of  the  stricture  feels  as  a  hard  Masses  of  new  growth  are  to  be  felt,  either  as 
ridge  in  the  tissues  of  the  bowel.  Poly-  flat  plates  between  the  mucous  membrane 
poid    growths,   if    present,   are    felt    to    be  and    the    muscular    tunic,   or    as    distinct 

attached  to  the  mucous  membrane.  tumors   encroaching  on  the   lumen   of  the 

bowel. 
Ulceration  of  tlic  mucous  membrane  may  be     Ulceration,    when    present,   is    evidently    the 
present,  but   without   any  great   induration  result  of  the    breaking   down   of  the   neo- 

of  the  edges.  plasm,  and  the  edges  are  much  thickened 

and  infiltrated. 
The  entire  circumference  of  the  bowel  is  con-     Generally  one  portion  of  the  circumference  is 

stricted  unless  the  stricture  is  valvular.  more  obviously  involved. 

Pain,  throughout  the  whole  course,  is  in  direct  For  the  advanced  stages  pain  is  frequently 
proportion  to  the  fecal  obstruction,  and  only  referred  to  the  sensory  distribution  of  some 
complained  of  during  the  effort  of  defeca-  of  the  branches  of  the  sacral  ple.xus,  due  to 

tion.  direct  imjilication  of  their  trunks. 

Glands  not  involved.  The   sacral   lymphatic  glands  can  sometimes 

be  felt  through  the  rectum  to  be  enlarged 
and  hard. 

Treatment. — The  diet  of  the  patient  requires  careful  attention.  It 
should  be  nutritious,  containing  such  articles  as  leave  a  small  residue. 
The  feces  should  be  kept  soft.  When  the  stricture  is  due  to  syphilis 
or  tuberculosis  the  general  treatment  of  these  diseases  must  be 
employed.  The  local  treatment  of  stricture  must  depend  upon  the 
variety.  Many  annular  strictures  can  be  completely  cured,  while  tub- 
ular strictures  are  frequently  beyond  the  reach  of  local  treatment. 
The  operative  treatment  may  be  considered  under  the  following  heads : 

{a)  Gradual  Dilatation. — Bougies  have  been  so  much  abused  that 
it  is  difficult  to  estimate  their  proper  value.  When  they  are  employed 
to  overcome  a  stricture  it  should  be  clearly  understood  by  both  patient 
and  surgeon  that  a  long  course  of  treatment  will  be  necessary.  With- 
out this  understanding  it  is  useless  to  begin.  An  annular  stricture  may 
be  compared  to  a  rubber  ring.  The  passage  of  a  bougie  will  dilate  the 
ring,  but  it  speedily  returns  to  its  original  size.  The  use  of  the  instru- 
ment daily  for  weeks,  and  even  months,  will,  however,  in  many  cases 
finally  overcome  the  elasticity  and  cause  the  stricture  to  disappear. 
This  little  operation  is  very  simply  done,  and  especially  in  stricture  low 
down  the  patient  or  a  nurse  with  very  little  instruction  can  attend  to 
the  treatment.  Great  care  should  be  taken  to  make  sure  that  the 
instrument  really  passes  through  the  stricture.  Sometimes  a  pouch 
forms  below  the  stricture,  and  into  this  the  nurse,  or  even  the  physician, 
has  been  known  to  pass  a  bougie  daily  for  weeks  in  the  belief  that  he 
was  dilating  the  stricture. 

Half  an  hour  before  using  bougies  it  is  best  to  give  the  patient  an 
enema  of  warm  oil  and  water,  which  not  only  empties  the  bowel,  but 
quiets  the  irritability  of  the  sphincter  (Cripps).  The  patient  lies  on  his 
side  with  one  knee  drawn  up.  Beginning  with  a  size  which  easily 
passes  through  the  stricture,  larger  instruments  are  employed  as  dilata- 
tion advances.  Great  benefit  is  obtained  by  keeping  the  instrument  in 
position  from  a  few  minutes  to  several  hours  a  day  as  the  patient  can 
bear  it. 


INJURIES  AND  DISEASES   OF   THE  DIGESTIVE   SYSTEM.       345 

{p)  Forcible  Dilatation. — This  method  is  attended  with  too  much 
risk  to  warrant  a  recommendation.  A  stricture  when  forcibly  dilated 
gives  way  at  its  weakest  point,  and  that  is  usually  Douglas's  cul-de-sac. 
The  consequence  of  such  an  accident  is  the  pouring  of  the  fecal  con- 
tents of  the  bowel  into  the  peritoneal  cavity,  followed  by  general 
peritonitis  and  death.  So  great  is  the  risk  of  rupture  that  in  no  case 
should  an  attempt  be  made  to  force  the  finger  through  a  tight  stricture 
for  the  purpose  of  ascertaining  the  condition  of  the  bowel  higher  up. 
The  only  strictures  of  the  rectum  in  which  forcible  dilatation  can  be  at 
all  warranted  are  those  within  an  inch  of  the  anal  margin. 

(r)  Litcrnal  Division. — This  is  another  dangerous  operation.  An 
incision  in  the  rectum  is  almost  sure  to  result  in  suppuration,  with 
formation  of  abscess  and  burrowing  of  pus  in  various  directions.  The 
cause  of  this  is  readily  explained.  The  sphincter  ani  closes  with  more 
or  less  accuracy  the  lower  end  of  the  rectum,  and  acts  as  a  barrier  to 
the  downward  pressure  of  the  bowel-contents.  Before  the  resistance 
of  the  sphincter  can  be  overcome  the  rectum  is  distended,  and  with  the 
distention  a  stretching  of  the  incision.  This  not  only  prevents  heal- 
ing but  allows  fecal  matter  to  get  into  the  incision  and  produce  sup- 
puration. 

id')  Posterior  Division  of  the  Stricture  and  External  Parts. — The 
great  objection  to  internal  division  is  the  impossibility  of  free  drainage. 
That  objection  is  overcome  when  a  free  division  is  made,  not  only  of 
the  stricture,  but  of  all  the  tissues  between  it  and  the  surface. 

Operation. — The  bowels  having  been  thoroughly  evacuated  by  a 
cathartic  followed  by  an  enema,  the  patient  is  placed  in  the  lithotomy 
position.  The  finger  of  the  left  hand  is  pressed  through  the  stricture. 
If  this  is  impossible,  a  probe-pointed  bistoury  is  passed  through,  and,  its 
edge  being  directed  backward,  the  stricture  is  cut  exactly  in  the  middle 
line  sufficiently  to  allow  the  finger  to  pass  through.  A  long  curved, 
sharp-pointed  bistoury,  guarded  by  the  finger-nail  or  a  director,  is  then 
passed  through  the  stricture ;  the  point  is  directed  backward  in  the 
middle  line,  and  made  to  transfix  the  rectal  wall  behind,  coming  out  at 
the  end  or  side  of  the  coccyx.  It  is  then  made  to  cut  its  way  out. 
Bleeding  points  are  ligated  as  far  as  possible.  A  drainage-tube  is  placed 
in  the  rectum,  its  upper  end  reaching  beyond  the  seat  of  the  operation. 
Around  the  tube  the  space  is  packed  with  iodoform  gauze  and  a 
T-bandage  applied.  The  packing  is  removed  daily,  the  parts  irrigated, 
and  again  packed.  About  the  tenth  day  bougies  are  passed  to  prevent 
recurrence  of  the  stricture,  and  this  is  continued  for  six  months. 
During  the  healing  a  full-sized  bougie  should  be  kept  in  for  several 
hours  a  day. 

{e)  Colostomy. — When  other  measures  are  unavailing  relief  from 
suffering  and  prolongation  of  life  can  be  obtained  by  the  formation  of 
an  artificial  opening  in  the  colon  (see  Colostomy). 

Congenital  Malformations  of  the  Rectum  and  Anus. — These 
malformations  are  the  result  of  arrested  development  in  early  fetal  life. 
The  bowel  and  the  sinus  from  which  are  later  developed  the  genital 
organs  are  not  at  first  separate  in  the  fetus.  If  the  opening  between 
the  two  persists,  malformation  is  the  result,  and  the  feces  may  pass  by 
the  urethra  (Fig.  151),  or  vagina,  or  the  bladder  (Fig.  152), 


346 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


If  not  wholly  absent,  the  rectum  and  anus  may  be  very  narrow,. 
though  not  entirely  occluded. 


Fig.  151. — Imperforate  anus,  the  rectum  terminating  in  the  urethra  (Gant). 

Imperforate  rectum  and  imperforate  anus   are  the  most  common 
deformities. 

The  bowel  is  developed  from  the  hypoblast,  except  the  lower  por- 


FlG.  152. — Imperforate  anus,  the  rectum  ter- 
minating in  the  bladder  (Gant). 


Fig.  153. — Imperforate  rectum,  the  anus 
natural,  but  rectum  separated  from  it  by  a 
membranous  partition  (Gant). 


tion,  which,  together  with  the  anus,  is  an  involution  from  the  epiblast. 
As  the  fetus  develops  the  bowel  pushes  its  length  dow^nward,  and  the 


THE    GENITO-URINARY  SYSTEM.  347 

involution  proceeds  upward  from  the  surface  to  meet  it.  Absorption 
of  intervening  tissue  takes  place,  and  the  two  become  one  continuous 
passage.  If  development  is  arrested  at  any  point,  imperforate  rectum 
or  anus,  or  both,  may  occur.  Should  the  involution  at  the  surface  not 
begin  at  all,  or  cease  after  a  mere  depression  has  taken  place,  the  con- 
dition is  known  as  imperforate  anus.  The  involution,  on  the  other 
hand,  may  proceed  to  a  normal  exent,  but,  the  bowel  not  descending 
sufficiently,  absorption  of  intervening  tissue  may  not  take  place, 
producing  a  condition   known   as  imperforate  rectum. 

All  degrees  of  malformation  may  exist — from  that  in  which  only  a 
thin  membrane  lies  between  the  rectum  and  anus  (Fig.  153)  to  those  in 
which,  by  absence  or  obliteration  of  the  rectum,  there  is  a  space  of 
several  inches  between  the  anus  and  the  bowel. 

Symptoms. — The  diagnosis  of  these  conditions  is  made  from  the 
fact  that  the  child  has  had  no  motion  from  the  bowels,  or  by  the  pres- 
ence of  a  fistula  connecting  the  bowel  with  the  bladder  or  urethra  or 
vagina,  through  which  the  feces  are  passed.  In  addition,  the  abdomen 
is  distended,  and  there  may  be  vomiting  severe  and  persistent. 

Treatment. — If  only  a  membrane  separate  the  rectum  and  anus 
(Fig.  153),  a  simple  incision  affords  an  opening.  During  the  process 
of  healing  care  must  be  taken  to  prevent  contraction  by  daily  insertion 
of  the  finger. 

If  the  rectal  pouch  is  situated  high  up,  but  low  enough,  so  that 
bulging  can  be  detected,  an  incision  should  be  made  in  the  median 
line.  All  tissues  are  dissected  away  until  the  pouch  is  reached.  It 
should  be  opened,  emptied,  cleansed  antiseptically,  and  its  edges 
sutured  to  the  edges  of  the  incision.  It  is  then  dressed  antiseptically, 
and  bougies  inserted  daily  to  prevent  contraction.  If  no  pouch  can 
be  detected,  an  incision  is  made  in  the  left  inguinal  region,  and  search 
made  for  the  end  of  the  bowel  and  inguinal  colostomy  performed. 

When  the  opening  is  into  the  urethra  or  vagina  this  fistula  should 
be  closed,  and  an  outlet  established  at  the  anus  if  possible ;  otherwise, 
in  the  left  inguinal  region,  as  in  high  imperforate  rectum. 


CHAPTER   VII. 
THE   GENITO=URINARY   5YSTEM. 

I.   INJURIES   AND   DISEASES  OF  THE   KIDNEYS. 

Surgical  Anatomy. — The  kidneys  lie  behind  the  peritoneum  deep 
in  the  lumbar  region  and  imbedded  in  abundance  of  loose  fatty  tissue. 
Each  kidney  lies  upon  the  posterior  portion  of  the  diaphragm,  the 
transversalis  aponeurosis,  and  the  psoas  muscle.  The  upper  end  of 
the  right  kidney  is  in  contact  with  the  under  surface  of  the  liver.  In 
front  the  anterior  surface  is  in  relation  with  the  duodenum  and  the  right 
flexure  of  the  colon.  The  upper  end  of  the  left  kidney  is  in  contact 
with  the  stomach  ;  its  outer  border  for  two-thirds  of  its  length  touches 


348  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

the  spleen,  and  its  lower  end  is  crossed  by  the  descending  colon  ;  in 
front  toward  the  inside  lies  the  pancreas.  The  upper  end  of  the  kidney 
corresponds  with  the  left  intercostal  space,  and  the  lower  end  is  on  a 
level  with  the  middle  of  the  third  lumbar  spine.  The  right  is  a  little 
lower  than  the  left,  owing  to  the  pressure  of  the  liver  from  above. 
The  left  kidney  may  occupy  a  position  above  the  spleen.  It  some- 
times happens  that  there  is  only  one  kidney.  In  this  case  the  organ  is 
large  enough  to  compensate  for  the  absent  one.  Sometimes  both  organs 
are  closely  united  at  their  extremities,  forming  the  "  horseshoe  "  kidney, 
so  called. 

The  kidneys  are  subject  to  great  variations  both  in  regard  to  the 
size  and  the  position  of  the  organs.  They  may  be  placed  as  low  down 
as  the  brim  of  the  pelvis  or  even  in  the  pelvic  cavity,  and  in  either  of 
these  situations  they  are  likely  to  give  considerable  trouble  during 
menstruation  or  in  the  progress  of  parturition.  The  vessels  may  also 
be  abnormal.  Thus  the  organ  may  receive  its  arterial  supply  from  a 
vessel  rising  from  the  aorta  higher  up  or  lower  down  than  in  the  nor- 
mal condition,  or  springing  from  the  common  iliac.  The  ureter  is  just 
as  variable.  Sometimes  it  is  double  either  at  its  origin  or  in  its  whole 
course,  or  it  may  be  tortuous,  especially  when  encroached  upon  by 
morbid  growths.  The  ureters  lie  obliquely,  and  in  such  a  position 
that  if  their  axes  were  prolonged  upward  they  would  meet  on  the 
ninth  dorsal  vertebra,  and  if  prolonged  downward  would  pass  over 
the  tips  of  the  iliac  crests.  The  inner  border  of  each  kidney  is  con- 
cave, forming  a  longitudinal  gap  called  the  hilum,  which  contains  three 
very  important  structures — viz.  the  renal  artery,  the  renal  vein,  and  the 
ureter.     These  constitute  the  pedicle  in  removal  of  the  kidney. 

The  arteries  arise  from  the  aorta  about  the  level  of  the  first  lumbar 
vertebra,  and  pass  almost  horizontally  to  the  kidneys.  The  right  ves- 
sel takes  a  slightly  upward  course  to  reach  its  organ  ;  it  passes  behind 
the  inferior  vena  cava,  and  is  of  course  longer  than  its  fellow,  for  the 
aorta  has  the  vena  cava  between  it  and  the  right  kidney.  The  left 
artery  generally  rises  a  little  higher  up  than  the  right.  Before  reach- 
ing the  hilum  each  arter}'  divides  into  three,  four,  or  five  branches 
which  go  to  supply  the  renal  tissue.  The  position  of  the  structures  at 
the  hilum  are,  from  above  downward  and  backward,  artery,  vein,  ureter. 

The  renal  veins  pass  at  right  angles  from  the  hilum  of  each  kidney 
to  enter  the  vena  cava  inferior.  The  left  vein  is  slightly  higher  and 
longer  than  the  right.  The  ureter  is  the  membranous  tube  which  con- 
veys the  urine  from  the  kidney  to  the  bladder.  It  is  about  fourteen 
inches  in  length  and  its  diameter  is  about  one-eighth  of  an  inch.  It 
begins  at  the  lower  border  of  the  kidney,  and  expands  into  a  funnel- 
shaped  sac  called  the  pelvis  ;  then  passes  down  behind  the  peritoneum 
lying  upon  the  psoas  muscle,  and  crosses  the  bifurcation  of  the  common 
iliac  artery  to  reach  the  base  of  the  bladder. 

Following  the  ureter  from  the  pelvis  into  the  substance  of  the  kid- 
ney, we  find  that  it  divides  into  two  or  three  short  trunks,  and  these 
again  subdivide  to  form  the  primary  tubes  or  infundibula  which  receive 
the  papillae. 

The  kidney  is  held  in  position  by  a  mass  of  fat  which  forms  its  bed. 
In  this  it  enjoys  a  slight  degree  of  mobility,  and  when  the  fat  is  opened 


THE    GENITO-URINARY  SYSTEM.  349 

up  the  kidney  may  be  seen  to  rise  and  fall  with  respiration.  Sometimes 
this  fatty  capsule  is  wanting,  and  the  organ  is  held  in  place  only  by  the 
blood-vessels  and  ureter  at  its  hilum,  or,  the  fat  being  lost  by  sudden 
emaciation  of  the  patient,  the  movements  of  the  kidney  are  greatly 
increased.  To  this  condition  the  name  "  movable  kidney  "  is  applied. 
Sometimes  the  peritoneum  invests  the  organ,  forming  a  mesonephron, 
and  the  kidney  becomes  displaced  into  the  general  peritoneal  cavity, 
moving  freely  in  every  direction  as  far  as  its  vessels  and  ureter  will 
permit.     To  this  abnormality  the  name  of"  floating  kidney  "  is  applied. 


Injuries  of  the  Kidney. 

The  kidneys  are  well  out  of  harm's  way,  being  protected  in  the  rear 
by  the  strong,  thick  muscles  of  the  lumbar  region,  and  in  front  by  the 
abdominal  wall  and  the  abdominal  viscera.  Injuries  of  the  kidney  are 
on  this  account  comparatively  rare.  They  may  be  divided  into  three 
classes  : 

I .  Contusion  without  I/aceration  of  the  External  Tissues. 
— This  is  one  of  the  most  frequent  of  renal  injuries.  It  may  be  pro- 
duced by  blows  or  falls,  especially  when  the  body  is  in  a  sitting  posi- 
tion or  forcibly  bent  forward  at  the  time  of  striking  the  ground. 
Another  common  cause  of  renal  contusion  is  a  squeezing  or  crushing 
of  the  loins  between  carriage  or  machine  wheels.  Whatever  the  cause, 
it  may  produce  injury  varying  from  little  discomfort  and  few  symptoms 
up  to  complete  rupture  and  even  pulpification  of  the  organ.  Trauma- 
tisms in  the  renal  region,  according  to  Kiister,  cause  either  laceration 
of  renal  tissue  or  mobility  of  the  organ.  As  a  rule,  laceration  occurs 
in  males,  mobility  in  females.  This  is  accounted  for  by  the  fact  that  in 
the  female  the  conformation  of  the  body,  the  thickness  of  the  adipose 
tissue,  and  the  protection  afforded  by  the  corset  break  the  direct  force 
of  a  blow,  and  thus  guard  against  lacerations.^ 

Synipt07iis. — The  violence  which  produces  the  kidney  lesion  is  likely 
to  cause  so  much  pain  in  the  loin  as  to  mask  the  symptoms  which  point 
more  directly  to  the  kidney.  The  pain  shoots  down  the  thigh  and  into 
the  testicle  and  loin.  If  the  kidney  is  injured,  we  have  in  addition  fre- 
quent micturition  and  sometimes  hematuria.  Blood  in  the  urine,  how- 
ever, is  a  symptom  that  must  be  carefully  weighed.  It  may  be  present 
when  there  is  sudden  congestion  in  any  portion  of  the  urinary  tract,  as 
in  violent  strains.  On  the  other  hand,  there  may  be  extensive  lacera- 
tion and  hemorrhage  from  the  kidney,  but,  owing  to  the  formation  of 
a  clot  in  the  ureter,  no  blood  escapes  with  the  urine. 

The  quantity  of  the  blood  that  escapes  is  very  variable.  When  it 
is  extravasated  around  the  kidney  it  causes  swelling  in  the  loin,  and  as 
the  blood-stained  serum  passes  downward  along  the  vessels  the  skin 
becomes  discolored  in  the  inguinal  region,  in  the  scrotum,  and  in  the 
thigh.  When  only  the  cortex  of  the  kidney  is  torn  the  hemorrhage 
is  usually  slight.  If  the  laceration  extends  into  the  hilum  or  a  vessel  of 
considerable  size  is  torn,  then  a  profuse  flow  of  blood  runs  down  the 
ureter,  filling  the  bladder,  and  perhaps  coagulating  therein.    The  symp- 

^  An7i.  of  Univ.  Med.  Set.,  1S96. 


350  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

toms  of  renal  colic  follow,  and  in  some  cases  long  worm-like  clots  are 
expelled  per  urethram.  There  is  intense  pain  about  the  pubes  and  at 
the  end  of  the  penis.  If  the  ureter  becomes  completely  occluded  by 
a  clot,  hydronephrosis  follows.  Still  more  copious  is  the  loss  of  blood 
when  the  peritoneum  is  ruptured  and  the  hemorrhage  is  poured  out 
into  the  abdominal  cavity.  The  symptoms  of  profuse  hemorrhage 
rapidly  come  on  and  the  patient  may  bleed  to  death  in  a  short  time. 

Extravasation  of  Jiri/ic  from  the  kidiuy  is  a  symptom  which  is  of 
rare  occurrence.  It  does  not  take  place  unless  the  pelvis  or  the  hilum 
is  ruptured.  Then  the  urine  is  poured  out  either  into  the  peritoneal 
cavity  or  into  the  areolar  tissue  around  the  kidney.  Inflammation 
follows,  and  often  results  in  suppuration  and  sloughing,  to  which  the 
patient  eventually  succumbs. 

Trcatinciit. — The  patient  should  be  kept  in  the  recumbent  posture 
and  fed  on  liquids.  The  loins  should  be  supported  by  a  broad  strip  of 
adhesive  plaster,  as  in  the  treatment  of  fractured  ribs.  Gallic  acid, 
ergot,  acetate  of  lead,  and  opium  are  valuable  in  checking  hematuria. 
The  bowels  can  be  relieved  by  enemata,  but  purgatives  are  to  be 
avoided.  When  the  bladder  is  filled  with  blood,  as  evidenced  by 
tenesmus  and  the  passage  of  clots,  every  care  must  be  taken  to  prevent 
cystitis.  A  double-current  catheter  should  be  inserted  and  irrigation 
carried  out  with  some  mild  disinfecting  fluid,  as  boric  acid  or  Thiersch's 
solution ;  or  one  of  the  evacuating  tubes  and  evacuators  used  in  lithot- 
rity  can  be  employed  to  throw  in  and  w^ithdraw  quantities  of  water 
from  the  bladder. 

When  the  coagula  are  so  large  and  firm  as  to  resist  these  methods 
perineal  section  is  indicated.  Severe  cases  w^iich  are  attended  with 
profound  shock  and  a  rapidly  increasing  tumor  in  the  loin  demand  a 
lumbar  incision.  After  exposing  the  kidney  the  bleeding  points  are 
sought  for  and  ligated ;  if  the  kidney  is  disorganized,  it  should  be 
removed. 

2.  Wound  of  the  Kidney  with  I/aceration  of  the  External 
Parts. — The  anterior  surface  of  the  kidney  may  be  penetrated  by  an 
instrument  or  missile  entering  the  abdomen  and  passing  through  both 
layers  of  peritoneum.  The  symptoms  in  this  case  are  those  of  hemor- 
rhage or  extravasation  of  urine  into  the  peritoneal  cavity.  When 
the  wound  is  received  in  the  loin,  the  posterior  surface  of  the  kidney  is 
the  part  to  suffer.  If  urine  escapes,  it  is  proof  positive  of  renal  lacera- 
tion, but  it  must  be  remembered  that  the  cortex  may  be  incised  with- 
out flow^  of  urine.  Hematuria  is  also  a  sign,  but  the  same  uncertainty 
attends  it  here  as  in  the  preceding  class  of  injuries.  Perinephric  abscess 
is  a  frequent  sequel  of  renal  wound.  Extra-peritoneal  wounds  gen- 
erally do  well,  but  those  which  are  intra-peritoneal  have  a  very  high 
mortality. 

Treatment. — Wounds  of  the  kidney  inflicted  through  the  loin  are 
extra-peritoneal  and  require  the  same  treatment  as  nephrotomy.  A 
drainage-tube  is  inserted  down  to  the  wound  in  the  kidney,  and  the 
surrounding  space  packed  with  strips  of  iodoform  gauze.  Should 
further  drainage  be  required,  the  external  wound  should  be  enlarged. 

3.  Intra-peritoneal  wounds  of  the  kidney  demand  celiotomy, 
and  in  most  instances  nephrectomy. 


THE    GENITO-  URINAR  Y  S  YSTEM.  3  5  I 


Diseases  of  the  Kidney. 


Bxamination  of  the  Kidneys. — In  the  injuries  which  have  just 
been  described  our  attention  is  naturally  directed  to  the  kidneys  by  the 
position  of  the  traumatism  and  the  nature  of  the  accident.  In  surgical 
diseases  of  these  organs  we  are  led  to  the  kidneys  by  the  general 
examination  of  the  patient.  When,  for  instance,  we  get  a  history  of 
violent  attacks  of  pain  in  the  loin  shooting  down  toward  the  bladder, 
the  testicle,  and  the  thigh,  we  suspect  renal  calculus,  and  the  suspicion 
grows  upon  us  if  we  learn  that  during  or  after  these  attacks  small 
quantities  of  bright-red  blood  have  come  away  with  the  urine.  Again, 
if  the  patient  complains  of  periodical  attacks  of  violent  pain  with 
marked  diminution  of  the  quantity  of  urine,  followed  by  a  copious 
flow  and  relief  of  all  symptoms,  we  suspect  hydronephrosis  due  to 
movable  kidney,  and  our  suspicion  is  confirmed  if  he  also  tells  us  that 
a  tumor  of  a  somewhat  erratic  character  can  be  felt  from  time  to  time. 

In  the  examination  of  the  kidney  our  methods  of  investigation  are 
somewhat  limited. 

Inspection  is  only  of  value  when  the  loin  is  greatly  distended  by  a 
solid  or  cystic  tumor,  in  cases  of  hydronephrosis  or  pyonephrosis,  in 
enlargement  of  the  kidney,  and  in  cases  of  hemorrhage  which  is  extra- 
peritoneal. 

Palpation  is  often  of  great  value.  The  healthy  kidney  of  normal 
size  and  lying  in  its  proper  position  is  beyond  the  reach  of  palpation. 
It  is  only  when  the  organ  is  enlarged  that  it  can  be  felt.  To  examine 
it  by  palpation  place  the  fingers  of  one  hand  just  below  the  twelfth  rib 
and  at  the  outer  edge  of  the  erector  spinae  muscle,  or  about  two  and  a 
half  inches  from  the  spinous  processes ;  the  other  hand  is  placed  on 
the  abdominal  wall  in  front.  The  enlarged  kidney  can  be  felt  between 
the  two  hands.  Sometimes  the  finger  and  thumb  of  one  hand  are 
sufficient,  and  in  this  way  a  good  idea  of  the  size  of  the  kidney  can  be 
obtained.  In  very  lean  persons  with  lax  and  thin  abdominal  walls  the 
lower  third  of  the  kidney  may  be  felt ;  with  this  exception,  if  you  feel 
the  kidney  at  all,  you  may  set  it  down  as  an  enlargement  of  the  organ. 
As  the  kidney  enlarges  it  extends  in  two  directions,  downward  and 
forward.  The  ribs  and  spinal  column  prevent  its  extension  backward, 
and  its  own  weight  tends  to  drag  it  downward.  Hence  the  greater 
the  enlargement  the  more  easily  can  the  kidney  be  palpated. 

Israel's  method  of  palpation  is  as  follows :  A  line  parallel  with  the 
middle  line  of  the  abdomen  is  drawn  from  the  middle  of  Poupart's 
ligament  to  the  margin  of  the  ribs.  The  finger-tips,  placed  two  finger- 
breadths  below  the  margin  of  the  ribs  and  upon  this  line,  are  directly 
over  the  lower  extremity  of  a  kidney  in  place.  In  order  to  feel  this 
kidney  we  must  avoid  poking  with  eager  hooked  fingers,  or  the 
abdominal  muscles  will  contract  in  resentment.  The  tips  of  the 
straight-extended  fingers  are  placed  upon  the  point  indicated  while  the 
patient  lies  supine,  with  flexed  legs,  upon  a  hard  bed  or  table;  The 
other  hand  now  lifts  the  loin  gently  toward  the  opposed  fingers.  At 
each  expiration  which  the  patient  makes  the  fingers  upon  the  abdomen 
are  pressed  a  little  farther  toward  the  kidney  ;  the  impress-fingers  easily 
recognize  the  object  sought  for.     If  the  patient  now  takes  a  full  breath. 


352  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

a  wandering  kidney  will  be  forced  far  under  the  finger-tips  (Israel,  cited 
by  Fenwick). 

Percussion. — The  solid  structures  which  surround  the  kidney 
render  its  percussion  impossible.  On  the  right  side  the  liver,  on  the 
left  the  spleen,  form  its  upper  boundary ;  behind  is  the  spine,  over  it 
the  muscles,  and  surrounding  it  a  mass  of  adipose  tissue.  There  is 
therefore  nothing  resonant  about  the  kidney  on  any  side.  Only  when 
the  organ  is  greatly  enlarged  can  we  gain  anything  from  percussion, 
and  then  it  simply  confirms  what  we  have  learned  by  palpation.  Some- 
times a  resonant  area  traverses  a  greatly  enlarged  kidney ;  tJiis  is  the 
distended  eolon. 

Exploratory  puncture  is  valuable,  and,  as  it  is  extra-peritoneal,  the 
danger  attending  its  employment  is  less  than  in  abdominal  explorations. 
In  hydronephrosis  and  pyonephrosis  the  needle  is  of  great  value,  for, 
having  established  the  diagnosis,  it  can  be  used  to  evacuate  the  fluid 
and  thus  produce  relief,  possibly  a  cure. 

Movable  Kidney. — Care  should  be  taken  to  avoid  the  common 
error  of  confusing  the  terms  movable  kidney  and  floating  kidney. 
Movable  kidney  is  an  acquired  condition  in  which  the  organ  remains 
behind  the  peritoneum,  but  with  more  or  less  movement.  It  is  simply 
loosened  up  in  its  fatty  bed.  Floating  kidney,  on  the  other  hand,  is  a 
congenital  abnormality  in  which  the  peritoneum  surrounds  the  kidney 
forming  a  renal  mesentery.  The  kidney  in  this  case  has  no  fatty  bed, 
but  floats  about  the  abdominal  cavity  as  far  as  its  mesentery  will 
permit. 

Movable  kidney  is  more  common  on  the  right  side  than  on  the  left, 
and  this  has  been  accounted  for  by  the  downward  pressure  of  the  liver. 
Women  suffer  more  frequently  than  men,  for  the  reason  that  repeated 
childbearing,  with  its  alternate  distention  and  relaxation  of  the  ab- 
dominal wall  and  sudden  loss  of  the  fatty  tissues  of  the  body,  is  a 
prominent  cause  of  renal  displacement. 

Symptoms. — The  sufferings  of  the  patient  depend  to  a  great  extent 
upon  the  degree  of  mobility  of  the  kidney.  There  may  be  only  slight 
discomfort  or  there  may  be  the  most  agonizing  pain.  When  there  is 
slight  mobility,  discomfort  is  usually  felt  after  exercise,  and  especially 
after  long  walks,  or  rides  in  which  there  is  much  jolting.  The 
menstrual  period  seems  to  have  a  powerful  effect  in  bringing  on  pain. 
There  is  a  sense  of  dragging  in  the  loin,  and  the  pain  shoots  down  the 
groin  and  the  thigh,  as  it  always  does  when  the  kidney  is  the  seat  of 
irritation.  Very  serious  and  alarming  symptoms  set  in  when  the  kidney 
turns  over  in  such  a  way  as  to  twist  its  pedicle  and  cause  obstruction  in 
the  ureter  and  the  renal  vessels.  The  urine,  no  longer  allowed  to  flow 
away,  distends  the  kidney,  producing  the  condition  known  as  hydro- 
nephrosis. W'hen  we  stop  to  consider  the  disturbances  which  would 
naturally  be  caused  by  a  kidney  distended  almost  to  bursting  by  the 
pent-up  urine,  we  can  readily  understand  the  remaining  symptoms. 
The  flow  of  urine  from  the  bladder  is  diminished.  Resorption  of  urea 
takes  place,  and  there  are  headache,  stupor,  foul  tongue,  vomiting,  and 
sometimes  jaundice.  In  nearly  all  cases  of  movable  kidney  the 
patients  are  nervous  and  hysterical.  Dyspepsia,  loss  of  appetite,  and 
general  debility  are  always  present.     On  palpation,  with  one  hand  at 


THE    GENITO-URINARY  SYSTEM.  353 

the  outer  border  of  the  erector  spinae  muscle  and  the  other  in  front, 
the  kidney  may  be  felt.  Sometimes  it  is  difficult  to  find  it,  and  the 
patient  should  be  placed  upon  his  hands  and  knees,  in  which  position 
the  kidney  falls  forward  upon  the  palpating  fingers.  Some  patients 
have  a  way  of  assuming  positions  which  bring  the  wandering  organ 
into  prominence,  and  I  am  in  the  habit  of  giving  them  an  opportunity 
of  doing  so. 

In  favorable  cases  a  tumor  can  be  felt  which  is  of  the  shape,  size, 
and  consistency  of  a  kidney.  It  is  freely  movable  over  a  certain  area, 
but  returns  naturally  to  the  normal  position  of  the  kidney  in  the  loin. 
Sometimes  the  organ  can  be  grasped  between  the  thumb  and  fingers 
of  one  hand  and  made  to  slip  from  place  to  place.  The  mobility  of 
the  kidney  may  give  one  loin  a  want  of  resistance  in  comparison  with 
the  other.  Pressure  applied  to  the  kidney  causes  a  sickening  pain  very 
similar  to  that  felt  in  the  testicle  or  ovary,  and  when  this  can  be  elicited 
in  a  movable  tumor  it  is  strongly  confirmator}^  of  a  wandering  kidney. 
The  failure  to  find  a  movable  tumor  by  palpation  must  not  be  taken  as 
settling  the  question.  If  the  other  symptoms  are  present  and  constant, 
and  if  they  are  breaking  down  the  patient's  health,  operative  procedure 
is  indicated. 

Diagnosis. — Many  other  tumors  are  liable  to  be  mistaken  for  mov- 
able kidney,  but  it  is  seldom  that  a  movable  kidney  is  mistaken  for 
anything  else.  The  history  of  the  case,  the  position  of  the  tumor,  its 
tendency  to  return  to  the  loin  after  it  has  been  pushed  to  the  length  of 
its  tether,  and  a  careful  study  of  the  symptoms  must  be  our  safeguard. 
Floating  kidney  cannot  be  positively  distinguished  from  movable  kid- 
ney by  any  symptom  yet  known.  The  length  to  which  a  mesonephron 
permits  the  kidney  to  wander  has  been  supposed  to  afford  a  criterion, 
but  when  a  movable  kidney  has  become  so  loose  that  its  movement  is 
only  restricted  by  the  renal  vessels  and  the  ureter,  it  has  every  charac- 
teristic of  a  floating  kidney. 

Treatment. — Inasmuch  as  exercise  and  jolting  of  the  body  increase 
the  suffering,  the  patient  should  be  kept  as  quiet  as  possible.  In  mild 
cases  patients  may  experience  great  relief  by  wearing  an  elastic  belt  with 
an  air-pad  so  constructed  as  to  push  the  kidney  well  back  into  the  loin. 
When  the  cause  of  mobility  is  the  loss  of  fat,  as  in  women  who  have 
undergone  rapid  emaciation,  an  attempt  should  be  made  to  restore 
normal  conditions  by  keeping  the  patient  in  bed  and  on  a  diet  which 
will  produce  the  greatest  amount  of  fat.  The  most  troublesome  cases 
are  those  in  which  renal  colic  occurs  from  twisting  of  the  pedicle. 
During  an  attack  perfect  quiet  in  the  dorsal  position  must  be  enjoined, 
with  hot  fomentations  and  sedatives  to  relieve  pain.  Such  cases  are 
not  infrequently  attended  with  degenerative  changes  in  the  kidney 
itself,  and  thus  the  condition  is  rendered  more  serious.  When  ordinary 
means  fail,  relief  must  be  sought  by  operation. 

The  operation  by  which  a  movable  kidney  is  made  to  form  attach- 
ments in  its  original  position  is  called  nephrorrhaphy  {yzippoz,  a  kidney ; 
^«^7^,  a  suture).  A  better  word  would  be  nephropexy  {yecpb:;,  a  kidney ; 
-rjyuoixc,  I  fix).  The  mortality  of  the  operation  is  probably  not  more 
than  2  per  cent.,  but  the  results  are  not  always  satisfactory.  The 
patient  is  placed  on  the  sound  side  with  a  firm  round  sand-bag  or 

23 


354  SURGICAL   DIAGNOSIS  AND    IIUiATMENT. 

pillow  under  the  body  to  increase  the  costo-iliac  space  as  much  as  pos- 
sible. The  incision  is  made  in  the  loin,  and  is  practically  the  same  as 
that  eniplo\-ed  in  lumbar  colotomy,  only  about  an  inch  farther  back. 
Its  bei^innini^  is  at  the  lower  border  of  the  twelfth  rib  and  at  the  outer 
border  of  the  erector  spinas  muscle.  This  point  is  generally  about 
two  and  a  half  inches  from  the  spinous  processes  of  the  vertebrjE. 
From  this,  as  a  starting-point,  the  incision  is  carried  downward  and 
outward  toward  the  crest  of  the  ilium  for  three  inches  or  more.  The 
skin  and  fat  are  divided  and  any  bleeding  points  secured.  The  super- 
ficial fascia  is  next  laid  open  to  the  full  extent  of  the  wound,  exposing 
the  outer  edge  of  the  latissimus  dorsi  and  the  posterior  border  of  the 
external  oblique.  Broad  retractors  in  the  hands  of  an  assistant  hold 
the  edges  of  the  wound  apart  and  afford  working  space.  The  edges 
of  these  muscles  are  divided  with  scissors  and  the  internal  oblique  and 
transversalis  come  into  view.  These  in  their  turn  are  severed  as  far  as 
the  upper  and  lower  limits  of  the  skin-wound,  and  lastly  the  deep 
layer  of  the  lumbar  aponeurosis.  The  peritoneal  fat  is  now  seen 
bulging  up  into  the  wound,  and  it  is  an  easy  matter  to  tear  it  apart 
with  scissors  and  expose  the  kidney  itself  To  bring  the  kidney  up 
to  position  an  assistant  with  strength  and  endurance  in  his  arm  pushes 
it  from  the  front.  In  all  operations  on  the  kidney  the  organ  gradually 
comes  up  into  the  wound  by  internal  abdominal  pressure,  so  that, 
although  it  may  seem  very  far  away  when  first  exposed,  it  comes 
nearer  and  nearer  to  the  surface  and  can  soon  be  conveniently  handled. 

Having  exposed  the  kidney,  two  fingers  are  passed  around  the  cap- 
sule to  ascertain  the  condition  which  is  the  cause  of  the  mobility.  By 
tearing  the  fatty  tissue  and  irritating  the  fibrous  capsule,  either  by 
manipulation  or  by  scratching  with  the  point  of  a  needle,  adhesive 
inflammation  will  be  induced,  and  upon  this  our  chief  reliance  must 
be  placed.  The  renal  capsule  is  opened  and  stripped  off  for  a  short 
distance,  so  as  to  expose  a  raw  surface  of  kidney.  Sutures  are  then 
passed  through  the  lumbar  aponeurosis,  the  capsule,  and  the  border 
of  the  kidney-substance.  Some  surgeons  fasten  the  kidney  to  the 
twelfth  rib,  and  with  a  show  of  reason,  for  when  the  organ  is  hardened 
ill  situ  it  bears  a  deep  groove,  which  is  the  impression  of  the  twelfth 
rib,  and  shows  that  in  normal  conditions  the  kidney  lies  in  contact  with 
that  bone.  Chromicized  catgut  is  a  suitable  material.  Its  service  is 
but  temporary,  for  it  only  keeps  the  parts  in  apposition  while  adhesive 
inflammation  is  taking  place.  Three  or  four  sutures  are  sufficient.  A 
drainage-tube  or  strip  of  iodoform  gauze  is  next  placed  in  the  wound 
with  its  inner  extremity  touching  the  kidney.  The  wound  is  closed 
with  silkworm  gut  and  a  full  dressing  applied.  The  patient  should  lie 
on  the  back  as  much  as  possible,  in  order  that  the  kidney  may  not 
gravitate  from  its  position,  and  should  keep  his  bed  for  six  weeks. 

Nephrectomy  has  been  resorted  to  for  the  worst  forms  of  movable 
kidney.  It  is  only  when  the  organ  is  diseased  as  well  as  distressingly 
movable  that  such  a  procedure  is  warrantable. 

Renal  Calculus. — Stones  are  formed  in  the  kidney  by  the  aggre- 
gation and  consolidation  of  certain  constituents  of  the  urine  which 
under  normal  conditions  the  kidneys  eliminate.  Of  this  class  the  most 
common   are  uric  acid  and  oxalate  of  lime.     In   unhealthy  conditions 


THE    GENITO-URINARY  SYSTEM.  355 

of  the  urine,  and  especially  when  it  undergoes  decomposition,  a  pre- 
cipitation takes  place  which  may  result  in  the  formation  of  stone. 
The  constituents  in  this  class  of  cases  are  most  commonly  phosphate 
of  lime  and  the  ammonio-magnesium  phosphate. 

Renal  calculi  vary  greatly  in  size,  number,  and  shape.  Frequently 
they  are  round,  and  so  small  and  smooth  that  they  pass  with  ease 
through  the  ureter  and  are  voided  in  the  urine.  Others  are  rough  and 
pointed  with  crystals,  so  that  on  their  passage  they  lacerate  the  deli- 
cate lining  of  the  urinary  passages  and  cause  it  to  bleed.  Others  are 
so  large  that  they  cannot  pass  away  from  the  kidney,  but,  continuing 
to  increase  in  size,  produce  one  of  the  most  distressing  conditions 
which  a  human  being  can  be  called  upon  to  endure — exciting  inflam- 
mation, stopping  the  flow  of  urine,  and  bringing  about  the  destruction 
of  the  kidney  itself 

Symptoms. — The  symptoms  of  renal  calculus  are  practically  those 
of  a  foreign  body  in  the  kidney.  Depending  upon  the  position  of  the 
stone  and  other  circumstances,  these  symptoms  are  subject  to  consider- 
able variation.  They  are  not  usually  all  present  in  any  given  case,  but 
the  cardinal  signs  are  not  often  wanting.     These  are  pain  and  hematuria. 

I.  Pai)2. — Two  kinds  of  pain  are  recognized,  direct  and  reflex. 
Direct  pain  may  be  constantly  felt  in  the  region  of  the  kidney  or  it 
may  only  be  present  when  the  patient  is  in  active  exercise.  Movement 
and  jolting  always  aggravate  it.  When  pressure  is  made  over  the  kid- 
ney or  the  organ  grasped  by  the  hands  in  the  loin  the  tenderness  is 
very  great. 

It  may  be  that  no  other  symptoms  are  manifested,  and  yet  a  diag- 
nosis of  stone  is  warranted,  and  it  may  further  be  assumed  that  the 
calculus  is  either  in  the  cortical  substance  or  in  some  part  of  the  kidney 
in  which  it  cannot  move. 

Very  different  is  the  character  of  the  suffering  when  the  calculus 
rolls  about  in  the  pelvis  of  the  kidney,  becomes  blocked  in  the  ureter, 
or  performs  its  painful  journey  to  the  bladder.  Renal  colic  is  the  name 
applied  to  these  attacks  when  they  appear  in  their  worst  form.  The 
local  pain  is  intense,  and  the  patient  clutches  the  affected  loin  as  if  to 
pluck  some  cruel  dart  from  his  tortured  flesh.  He  rolls  from  side  to 
side  bathed  in  perspiration  ;  rigors  are  frequent,  and  vomiting  is  often 
severe  and  persistent.  There  are  frequent  calls  to  micturate,  but  the 
quantity  of  urine  is  small.  All  this  time  the  stone  is  working  its  way 
down  the  slender  ureter,  rasping,  scratching,  and  tearing  the  delicate 
lining  and  causing  more  or  less  blood  to  flow.  At  last,  after  a  couple 
of  hours  or  it  may  be  several  days,  the  calculus  drops  from  the  ureter 
into  the  bladder.  If  it  be  true,  as  stated  by  some  old  philosopher, 
that  "  the  height  of  happiness  is  relief  from  pain,"  the  patient  expe- 
riences real  happiness,  for  the  pain  suddenly  ceases  and  a  great  calm 
follows  the  storm. 

But  a  well-marked  attack  of  renal  colic  may  occur  and  no  stone 
pass  into  the  bladder.  The  concretion  may  get  into  the  very  beginning 
of  the  ureter,  where  the  tube  is  larger  than  elsewhere  ;  it  goes  far 
enough  to  produce  occlusion  ;  the  urine  collects  behind  it,  producing 
hydronephrosis  ;  after  a  time  the  stone  drops  back  into  the  renal  pelvis 
and  the  pain  subsides. 


356  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

Reflex  pain  is  felt  at  a  distance  from  the  seat  of  trouble.  It  runs  to 
the  loin  and  the  testicle,  causing  the  latter  to  be  drawn  strongly 
upward.  It  runs  down  the  thigh  along  the  inner  side,  and  even 
extends  to  the  leg.  Sometimes  the  patient  traces  a  line  along  which  he 
says  the  pain  is  intensified,  and  this  line  corresponds  with  the  course 
of  the  ureter. 

It  must  be  carefully  borne  in  mind  that  stone  in  one  kidney  may 
cause  pain  in  the  opposite  organ.  Indeed,  cases  are  on  record  in  which 
all  the  symptoms  were  on  the  side  opposite  to  the  disease. 

2.  Blood  in  the  Jirinc  is  the  second  cardinal  symptom.  An  attack 
of  renal  colic  followed  by  hematuria  is  almost  pathognomonic  of  renal 
calculus.  The  blood  may  appear  in  the  form  of  small  rounded  clots  or 
it  may  be  mixed  with  the  urine  less  intimately  than  in  other  renal  dis- 
eases, but  more  freely  than  when  the  blood  comes  from  the  bladder  or 
prostate. 

Hematuria  may  be  absent  from  first  to  last.  When  the  urine  con- 
tains blood,  it  of  course  gives  the  test  for  albumin.  There  are  cases 
in  which  albuminuria  exists  without  the  presence  of  blood. 

Pus  is  frequently  found  in  the  urine  of  persons  suffering  from  stone 
in  the  kidney.  It  is  a  symptom  of  great  gravity.  It  proves  that 
inflammation  has  gone  on  to  suppuration,  and  that  destruction  of 
kidney-tissue  is  taking  place  which  may  result  in  complete  disorganiza- 
tion. Mucus  in  the  urine  is  also  an  important  symptom.  It  is  of 
special  significance  in  young  persons,  who  are  not  likely  to  suffer  from 
enlarged  prostate. 

In  the  majority  of  cases  the  diagnosis  of  stone  in  the  kidney  is  not 
difficult.  The  most  fruitful  source  of  error  is  stone  in  the  gall-bladder. 
It  is  remarkable  how  silent  the  text-books  are  upon  this  point,  and  yet 
there  are  cases  in  which  a  positive  diagnosis  is  impossible.  (See  Diag- 
nosis of  Gall-stones.)  The  differentiation  must  rest  upon  two  points  : 
I.  A  microscopical  examination  of  the  urine,  which  in  the  case  of  renal 
calculi  will  almost  surely  contain  blood-  or  pus-corpuscles.  2.  Tender- 
ness over  the  kidney.  Another  condition  simulating  in  some  degree 
the  passage  of  renal  calculi  is  the  discharge  of  tubercular  abscess  from 
the  kidney  to  the  bladder  by  way  of  the  ureter.  Considerable  pain 
may  be  experienced  and  the  symptoms  closely  resemble  renal  colic. 
In  gouty  persons  a  discharge  of  large  quantities  of  crystalline  uric  acid 
may  simulate  calculus,  but  in  either  of  the  above  the  history  will 
generally  remove  all  doubt. 

The  ;i--rays  have  been  successfully  employed  in  a  number  of  cases. 
In  one  case  which  came  under  my  observation  they  proved  misleading; 
the  skiagraph  seemed  to  reveal  a  stone,  but  on  operation  nothing  but  a 
healthy  kidney  was  found. 

Commencing  tuberculosis  in  the  kidney  may  lead  us  into  error. 
The  symptoms  already  laid  down  and  the  examination  of  the  urine  for 
the  tubercle  bacilli  will  generally  settle  the  question. 

The  pathological  condition  and  the  size  and  position  of  the  stone 
may  in  many  cases  be  diagnosticated.  When  pain  and  hematuria  are 
the  only  symptoms,  we  may  assume  that  the  kidney  is  Jicalthy  and  the 
calculus  large.  When  there  are  pus  in  the  urine,  a  swelling  or  increased 
resistance  in  the  loin,  and   tenderness  over  the  kidney,  an  abscess  with 


THE    GENITO-URINARY  SYSTEM.  357 

small  calculus  may  be  diagnosed.  Hydronephrosis,  as  evidenced  by  a 
swelling  in  the  loin,  which  is  not  tender  to  pressure  and  not  very  hard, 
accompanied  by  alkaline  urine,  little  pus,  and  repeated  attacks  of  renal 
colic,  points  to  a  stouc  that  is  blocking  the  uj'ctcr. 

Treatment. — During  attacks  of  renal  colic  pain  should  be  relieved 
by  hypodermic  injections  of  morphin  and  the  application  of  heat  to  the 
loin.  It  is  possible  to  aid  the  expulsion  of  a  small  stone  by  giving  the 
patient  bland  fluids  in  abundance  to  flush  the  urinary  tract.  These 
measures,  however,  will  in  the  great  majority  of  cases  be  of  little  or  no 
avail,  and  considering  the  stone  as  a  foreign  body,  the  only  hope  of 
permanent  benefit  lies  in  its  removal. 

Indicatitvis  for  Operation. — Not  every  renal  calculus  requires  an 
operation.  If  the  stone  is  lying  quietly  in  its  bed,  producing  no  pain 
and  causing  no  serious  mischief,  it  should  be  let  alone.  When  attacks 
of  renal  colic  follow  closely  upon  each  other,  making  the  patient's  life 
a  burden  and  preventing  him  from  following  his  occupation,  then  an 
operation  is  clearly  indicated.  Even  if  the  diagnosis  be  shrouded  in 
more  or  less  doubt,  an  incision  for  exploratory  purposes  should  be 
undertaken. 

Operation. — For  the  operation  of  nephro-lithotomy  the  incision  is 
the  same  as  that  described  under  Nephrorrhaphy.  When  the  kidney  is 
exposed  the  finger  should  be  passed  over  its  surface  both  before  and 
behind  in  search  of  inequalities  which  would  indicate  the  presence  of  a 
stone,  a  collection  of  fluid,  a  new  growth,  or  abnormal  mobility  of  the 
organ.  Failing  to  find  evidence  of  a  calculus  by  digital  examination,  a 
fine  aspirating  needle  can  be  used  with  the  view  of  searching  for  stone 
or  of  finding  a  cavity  containing  pus  or  other  fluid.  As  a  means  for 
finding  stone  I  am  convinced  that  punctures  with  a  needle  are  of  very 
little  value.  In  one  case  I  passed  a  needle  in  about  a  dozen  places 
without  feeling  the  least  sensation  of  the  instrument  touching  a  stone, 
and  yet  when  I  laid  the  kidney  open  forty  small  stones  were  removed. 
Influenced  by  this  and  several  similar  experiences,  I  have  come  to  the 
conclusion  that  when  digital  examination  fails  to  find  a  stone  the  next 
step  should  be  to  lay  the  kidney  open.  By  such  an  incision  an  abscess 
can  be  evacuated  or  a  stone  in  the  pelvis  of  the  kidney  exposed.  The 
opening  should  be  made  on  the  convex  surface  of  the  kidney  and  large 
enough  to  admit  the  fore  finger.  If  no  stone  can  be  felt  by  the  finger 
in  the  pelvis  of  the  kidney,  a  uterine  probe  bent  so  as  to  form  a  short- 
beaked  sound  is  employed  to  search  the  calyces.  A  flexible  probe  can 
be  passed  down  the  ureter  to  the  bladder.  When  a  stone  is  found  it  is 
removed  by  forceps.  If  the  calculus  be  branched  so  as  to  fill  a  number 
of  the  calyces,  it  may  be  necessary  to  break  it  into  fragments  before 
removal.  These  cases  are  often  exceedingly  troublesome,  and  require 
the  utmost  perseverance  and  ingenuity  of  the  surgeon.  Having  gotten 
rid  of  the  stone,  a  drainage-tube  is  introduced  down  to  the  opening  in 
the  kidney.  Around  the  tube  is  placed  a  packing  of  iodoform  gauze, 
the  wound  in  the  loin  is  closed  except  at  the  point  of  exit  of  the  tube, 
and  a  dressing  applied. 

Nephrectomy  (removal  of  the  kidney)  is  indicated  when  the  organ  is 
so  disorganized  by  the  presence  of  stones  or  from  any  other  cause  that 
it   cannot  return  to   its  normal   condition.      When   calculi   are  found 


358  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

imbedded  in  abscess-cavities  this  question  must  be  considered,  for  it  is 
better  to  remove  a  kidney  that  is  riddled  with  abscesses  than  to  let  it 
remain  with  the  certainty  of  a  second  operation  later  on.  To  remove 
a  kidney  is  a  serious  consideration.  The  question  of  throwing  the 
whole  of  the  work  on  one  kidney  is  by  no  means  the  most  serious 
problem  involved.  If  the  remaining;  or<^an  be  healthy,  it  is  probably 
already  doing  its  own  work  and  that  of  its  fellow. 

In  a  case  of  nephrectomy  for  chronic  abscesses  I  found  that  the 
patient  was  voiding  thirty-one  ounces  of  urine  daily ;  in  the  twenty- 
four  hours  following  the  operation  it  amounted  to  twenty-nine  ounces ; 
and  at  the  end  of  three  or  four  days  it  was  restored  to  the  normal 
quantity. 

A  much  more  serious  question  is  the  possibility  of  there  being  only 
one  kidney.  In  one  out  of  every  four  thousand  persons  all  the  renal 
substance  is  enclosed  within  one  capsule,  the  removal  of  which  would 
leave  no  kidney  at  all.  Another  consideration  is  the  possibility  that 
both  kidneys  are  diseased.  Assuming  that  one  kidney  is  so  seriously 
diseased  as  to  warrant  its  removal,  the  state  of  the  other  organ  must 
be  systematically  examined.  A  good  routine  method  of  investigation 
is  the  following : 

1.  Examine  the  organ  by  inspection,  palpation,  and  percussion. 

2.  By  repeated  examinations  of  the  urine  satisfy  yourself  that  a 
normal  quantity  and  quality  is  being  voided.  The  quantity  of  urea 
should  be  carefully  noted. 

3.  Examine  the  interior  of  the  bladder  with  the  cystoscope.  The 
pumping  action  of  the  ureters  can  in  this  way  be  brought  under  obser- 
vation, and  the  appearance  of  the  urine  as  it  escapes  from  each  ureter 
can  be  studied. 

4.  In  the  female  the  ureters  should  be  catheterized.  (See  Cystos- 
copy.) 

The  operation  of  nephrectomy  is  thus  performed :  The  incision  is 
the  same  as  for  nephrorrhaphy  or  nephro-lithotomy.  After  exposing 
the  kidney  the  finger  is  made  to  pass  around  it  on  every  side  to  free 
the  organ  from  its  fatty  capsule.  It  is  then  very  carefully  drawn  into 
the  wound  as  far  as  possible  and  handed  to  an  assistant.  The  next  step 
in  the  operation  is  to  find  and  secure  the  pedicle.  In  this  case  the 
pedicle  consists  of  the  renal  artery  and  veins  and  the  ureter.  The 
fingers  of  the  operator  tease  out  the  fat  about  the  pelvis  of  the 
kidney,  exposing  the  vessels.  The  pulsation  in  the  renal  artery  is  a 
guide  of  great  value.  Two  ligatures  are  necessary — one  for  the  vessels, 
the  other  for  the  ureter.  A  pedicle-needle  armed  with  a  stout  silk 
thread  is  made  to  surround  the  vessels  which  form  the  upper  part  of 
the  pedicle.  The  ligature  is  then  tied,  care  being  taken  that  during  the 
tightening  the  assistant  relaxes  the  traction  on  the  kidney.  The  ureter 
is  then  isolated  and  clamped  with  a  pair  of  forceps  as  a  temporary 
measure.  The  kidney  is  now  cut  away.  To  be  on  the  safe  side 
against  cutting  too  closely  to  the  ligature,  a  strong  pair  of  forceps 
may  be  placed  upon  the  pedicle  between  the  ligature  and  the  kidney. 
By  cutting  on  the  outside  of  the  forceps  ample  space  will  be  given 
to  prevent  slipping  of  the  ligature.     We  must  relax  tension  on  the 


THE    GENITO-URINARY  SYSTEM.  359 

pedicle  while  the  ligature  is  applied ;  we  must  be  equally  careful  to  do 
the  same  thing  while  the  pedicle  is  being  divided,  for  an  arter>^  put  on 
the  stretch  at  this  critical  juncture  might  retract  beyond  the  ligature 
and  produce  fatal  hemorrhage.  The  kidney  disposed  of,  attention  is 
now  turned  to  the  ureter  which  was  left  secured  by  a  clamp-forceps. 
If  there  is  no  thickening  of  the  walls  of  the  duct,  it  can  be  secured  by 
a  strong  silk  ligature  and  dropped  into  the  cavity.  If  there  is  much 
thickening  or  ulceration  in  its  walls,  it  is  best  to  attach  it  to  the 
parietal  wound. 

In  the  case  of  a  large  suppurating  kidney  there  may  be  no  room  for 
the  application  of  a  ligature  between  the  aorta  or  vena  cava  and  the 
kidney.  A  temporary  elastic  ligature  can  then  be  thrown  around  the 
base  of  the  kidney  and  the  diseased  organ  cut  away  with  scissors. 
This  will  do  away  with  the  risk  of  making  too  great  traction  on  the 
pedicle,  and  by  cutting  it  away  in  pieces  will  allow  a  greatly  enlarged 
kidney  to  be  delivered  through  the  parietal  wound.  As  soon  as  the 
kidney  is  removed  the  pedicle  is  secured  by  ligatures,  forceps,  or  actual 
cautery  and  the  elastic  band  removed. 

If  there  is  any  apprehension  of  hemorrhage,  strong  forceps  can  be 
applied  to  the  pedicle  and  left  in  position  for  thirty-six  hours.  They 
serve  an  excellent  purpose  in  the  way  of  drainage.  The  external 
wound  is  stitched  with  silkworm  gut  and  a  full  absorbent  dressing 
packed  around  the  forceps. 

When  the  forceps  are  not  loft  in  the  wound,  a  full-sized  drainage- 
tube  is  inserted  and  the  opening  closed  and  dressed  as  in  the  pre- 
ceding operations. 

Abdominal  nephrectomy  is  rarely  indicated.  It  has  one  advantage 
over  the  lumbar  operation,  in  that  the  operator  can  settle  the  question 
of  the  presence  and  integrity  of  the  opposite  kidney.  It  is  more 
suitable  than  the  lumbar  operation  for  large  movable,  non-adherent 
tumors  and  for  a  movable  kidney  which  has  become  diseased  and  does 
not  admit  of  lumbar  nephrectomy. 

The  incision  is  made  in  the  linea  alba  or  in  the  linea  semilunaris. 
The  length  should  in  no  case  be  less  than  four  inches,  for  it  will  be 
necessary  to  admit  the  whole  hand.  For  the  removal  of  large  tumors 
the  incision  must  be  correspondingly  extended.  The  middle  of  the 
incision  should  be  on  a  level  with  the  umbilicus.  Having  entered  the 
abdominal  cavity,  the  first  point  to  settle  is  the  condition  of  the  other 
kidney  by  direct  palpation.  Satisfied  on  this  point,  the  peritoneum  over 
the  diseased  organ  is  scratched  through.  This  opening  must  be  in  the 
outer  layer  of  the  mesocolon.  The  fingers  separate  the  front  of  the 
kidney  from  its  fatty  capsule.  The  pedicle  is  exposed  and  one  ligature 
passed  around  the  vessels,  while  strong  forceps  secures  the  ureter. 
The  kidney  is  then  cut  away  at  a  safe  distance  from  the  ligature,  and 
all  bleeding  points  carefully  secured.  The  ureter  is  dealt  with  accord- 
ing to  circumstances.  If  healthy,  it  is  washed,  ligated,  and  allowed  to 
drop.  If  suppurating,  it  can  be  secured  in  the  parietal  wound  or 
brought  through  an  opening  in  the  loin.  This  will  allow  of  its  being 
irrigated  from  time  to  time  and  will  prevent  the  formation  of  an  abscess. 
The  question  of  abdominal  drainage  here  is  settled  by  the  rules  which 
govern  it  in  other  celiotomies.     If  pus  or  urine  has   escaped  into  the 


360  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

peritoneal  cavity  during  the  operation,  a  drainage-tube  should  be 
inserted,  otherwise  it  is  not  necessar\'. 

Perinephritic  and  Nephritic  Abscess. — Suppuration  occurs 
around  the  kidney  as  a  result  of  direct  violence,  such  as  blows  or  kicks 
upon  the  loin.  It  may  be  produced  by  the  presence  of  a  renal  calculus 
or  it  may  spread  from  more  distant  organs,  such  as  the  liver,  gall- 
bladder, spleen,  the  intestine,  or  the  vertebrae.  Urinary  fistula  and 
extravasation  of  urine  are  also  causes.  It  not  infrequently  happens 
that  a  perinephritic  abscess  is  a  metastasis  from  some  distant  organ,  or 
it  may  be  a  direct  migration  of  septic  infection  from  the  urethra  or 
bladder. 

Symptoms. — The  local  symptoms  of  a  typical  perinephritic  abscess 
are — tenderness  in  the  loin  with  swelling  more  or  less  tense,  the  swell- 
ing and  tenderness  being  due  to  a  collection  of  pus.  We  naturally 
look  for  fluctuation,  but,  owing  to  thickness  of  the  overlying  tissues,  it 
is  generally  impossible  to  find  it.  To  wait  for  the  abscess  to  come  near 
enough  to  enable  us  to  find  fluctuation  would  be  bad  surgery.  Much 
better  is  it  to  make  an  exploratory  puncture  or  incision  and  settle  the 
question.  No  harm  can  come  from  it,  and  neglect  of  this  measure 
may  prove  disastrous. 

The  general  symptoms  are  those  of  suppurative  inflammation,  high 
temperature,  rapid  pulse,  chills,  and  general  malaise. 

In  the  course  of  time  the  pus  has  a  tendency  to  burrow  in  one  of 
several  directions  and  the  symptoms  are  modified  accordingly.  It  is  a 
rare  event  for  the  abscess  to  rupture  into  the  peritoneal  cavity.  When 
this  happens  the  symptoms  are  those  of  general  peritonitis.  The  most 
common  directions  in  which  the  pus  is  likely  to  burrow  are  the  fol- 
lowing : 

1.  It  is  confined  by  the  fascia  surrounding  the  neighboring  muscles, 
and  eventually  points  in  the  loin.  In  this  case  we  will  have  pain, 
tenderness,  swelling,  edema,  and,  at  a  late  stage,  fluctuation  in  the  loin. 

2.  The  pus  gets  into  the  sheath  of  the  psoas,  and,  following  the 
course  of  that  muscle,  points  in  the  inguinal  region  after  the  manner 
of  a  psoas  abscess.  The  psoas  being  involved,  we  naturally  find  the 
muscle  contracted.  Hence  the  hip  is  flexed  and  the  patient  is  unable 
to  extend  the  thigh.  Pain  is  felt  in  the  thigh  and  may  run  down  the 
obturator  nerve  to  the  knee.  Reflected  pain  is  felt  in  the  testicle  or 
vulva. 

3.  The  pus  burrows  upward  through  the  diaphragm,  and,  pene- 
trating the  lung,  is  got  rid  of  by  expectoration.  Here  we  must  be  on 
our  guard  lest  the  pleuritic  and  pulmonary  symptoms  divert  our  atten- 
tion entirely  from  the  kidney.  In  a  case  which  came  under  my  care  in 
1 884  a  fistulous  opening  in  the  fifth  interspace  on  the  left  side  was  sup- 
posed to  be  due  to  empyema.  On  passing  a  flexible  catheter  through 
the  opening  it  took  a  direction  directly  downward  and  was  arrested  in 
the  loin.  Cutting  down  upon  the  end  of  the  catheter,  the  sinus  was 
traced  directly  to  the  kidney.  Free  dilatation  and  drainage  stopped  the 
suppuration.  When  pus  takes  this  upward  course  we  expect  to  find 
pleuritic  friction,  effusion  and  empyema,  dyspnea  and  expectoration  of 
pus.  On  the  right  side  the  liver  is  liable  to  be  involved,  hence  jaun- 
dice is  a  common  symptom  ;  the  stomach  sympathizes,  and  there  is 


THE    GEAVTO-CNnVARY  SYSTEM. 


361 


vomiting ;  pressure  interferes  with  the  venous  circulation,  and  there  is 
ascites.  In  rare  cases  perinephritic  abscesses  have  burst  into  the  colon, 
the  duodenum,  and  the  bladder. 

Trcatvioit. — Hot  fomentations  give  temporary  relief,  but  valuable 
time  should  not  be  wasted 
in  employing  such  reme- 
dies. The  proper  treat- 
ment is  to  make  an  incis- 
ion, wash  out  the  pus,  and 
drain  the  cavity. 

The  term  nephritic  ab- 
scess is  to  be  restricted  to 
a  collection  of  pus  in  a 
kidney  otherwise  healthy. 
Abscesses  of  this  charac- 
ter seldom  contain  more 
than  half  an  ounce  of  pus. 
The  tendency  is  for  the 
pus  to  find  its  way  into 
the  pelvis  of  the  kidney, 
thence  being  expelled  with 
the  urine,  recovery  taking 
place.  The  symptoms  are 
usually  severe  at  the  out- 
set of  acute  cases,  while  in 
chronic  cases  there  may 
be  little  or  no  fever.  Pain 
is  usually  felt  in  the  loin 
and  is  intense ;  rigors  oc- 
cur at  frequent  intervals, 
and  the  temperature  is 
high.  There  is  a  feeling 
of  increased  resistance  in 
the  loin,  and  sometimes 
there  are  redness  and  ede- 
ma of  the  skin.  The  urine 
should  be  carefully  exam- 
ined for  pus  ;  if  it  occur  in 
considerable  quantity  and 
is  followed  by  diminution 
of  a  tumor  in  the  loin,  a 
diagnosis  of  renal  abscess 
can  be  made  with  certainty. 

Treatment. — I  n  c  i  s  i  o  n 
is    the    proper    treatment. 


Fig.  154. — Suppuration  in  right  kidney,  ureters,  blad- 
der, and  prostate  from  stone  in  the  bladder.  The  left 
ureter,  filled  with  water,  measured  J-i  in.  in  diameter. 
The  capacity  of  the  bladder  was  only  9  drams.  The  blad- 
der contained  a  calculus  i^  in.  in  diameter  (from  a  photo- 
graph in  the  collection  of  Dr.  Jepson,  Sioux  City,  Iowa). 


Sometimes    the    pus    lies 

beneath    the    capsule    of 

the  kidney,  and  a  simple  incision  of  the  membrane  is  sufficient.     When 

it  lies  deeper  in  the  substance  of  the  organ  the  kidney  must  be  incised 

and  drained. 

Surgical  Kidney. — This  is  an  unfortunate  choice  of  a  name,  and 


362  SURGICAL    DIAGNOSIS  AXD    71-:EATiMENT. 

means  iiothini:^.  It  is  used  to  designate  a  general  suppuration  in  the 
kidne\'  which  is  secondary  to  sujjpuration  of  the  urinary  tract  lower 
down,  as,  for  instance,  in  the  bladder  or  urethra  (Figs.  154,  155).  It 
was  observed  to  frequently  follow  surgical  operations  on  these  parts, 
and  hence  the  name   "  surgical   kidney."      In   reality,  it  is  more  fre- 


FlG.  155. — Left  kidney  of  same  case  as  Fig.  154.  It  is  laid  open  to  illustrate  to  what  extent 
the  secreting  structure  was  absorbed.  It  is  simply  a  large  pus-sac  ;  the  walls  in  some  places 
are  no  thicker  than  brown  wrapping-paper  (from  a  photograph  in  the  collection  of  Dr.  Jepson, 
Sioux  City,  Iowa). 

quently  the  result  of  the  lack  of  surgical  procedures,  and  is  to  be 
traced  to  infection  spreading  unchecked  up  the  ureters  to  the  pelvis 
and  lastly  to  the  renal  cortex.  The  disease  frequently  affects  both 
kidneys  simultaneously,  both  being  equally  exposed  to  infection. 

Symptoms. — The  patient  is  usually  a  sufferer  from  some  chronic 
urinary  disorder,  as  stricture  or  enlarged  prostate,  requiring  the  fre- 
quent use  of  a  catheter.  The  extension  of  sepsis  to  the  kidney  is 
observed  after  the  employment  of  catheters  or  other  instruments,  but 
it  may  be  entirely  independent  of  them.  At  first  the  symptoms  are 
of  a  typhoid  character.  The  patient  becomes  feverish,  has  a  furred 
tongue,  dry  skin,  foul  breath,  and  is  restless  and  sleepless.  Rigors 
are  frequent,  sweating  profuse,  and  emaciation  becomes  marked.  The 
urine  generally  contains  pus  and  is  ammoniacal.     Death  by  exhaustion 


THE    GENITO-URINARY  SYSTEM.  363 

is  the  rule,  but  in  some  cases  suppression  of  urine,  followed  by  uremia, 
brings  about  a  painless  dissolution. 

Treatment. — Prevention  is  better  than  cure.  In  every  case  requiring 
the  use  of  a  catheter  or  the  simplest  operative  procedure  on  the  ure- 
thra or  bladder  the  greatest  care  should  be  taken  to  disinfect  the  seat 
of  operation  and  the  instrument  employed.  When,  after  the  use  of  a 
catheter,  symptoms  of  urethral  fever  set  in,  the  urine  should  be  dis- 
infected by  the  administration  of  salol  or  quinin,  and  the  patient  kept 
on  nutritious  and  easily  digested  food.  Should  there  be  evidence  of 
cystitis  or  an  unhealthy  condition  of  the  urine,  a  soft-rubber  catheter 
should  be  introduced  with  the  least  possible  irritation  and  the  bladder 
washed  out  with  boracic-acid  solution.  When  there  is  suppurative 
cystitis  the  bladder  should  be  washed  out,  and  injected  with  an  ounce 
of  water  containing  three  grains  of  nitrate  of  silver,  after  which  the 
bladder  should  be  again  irrigated  with  sterilized  water.  The  question 
of  nephrotomy  for  surgical  kidney  is  advisable  in  certain  cases.  If 
there  be  evidence  of  renal  abscess  and  the  condition  of  the  patient 
will  justify  it,  an  exploratory  incision  should  be  made  over  one  kidney 
in  the  hope  of  giving  exit  to  an  abscess  or  of  checking  the  septic  process 
by  incision  and  drainage. 

Hydronephrosis. — The  kidney  may  be  compared  to  a  lake  among 
the  hills,  drawing  its  water  from  numberless  springs  and  rills,  and  hav- 
ing as  its  outlet  a  mountain-stream  which  bears  the  surplus  water  to 
the  sea.  If  from  any  cause  the  outlet  becomes  obstructed,  the  lake 
must  overflow.  So  it  is  with  the  kidney  when  its  outlet,  the  ureter, 
becomes  impervious.  The  numberless  tubules  like  tiny  mountain-rills 
continue  to  pour  urine  into  the  renal  pelvis,  from  which  there  is  no 
escape  ;  the  pelvis  and  calyces  expand,  eventually  forming  a  tumor  in 
the  loin  attended  with  most  disagreeable  symptoms.  It  is  a  serious 
matter  when  one  kidney  is  thus  affected ;  it  is  disastrous  when  hydro- 
nephrosis occurs  simultaneously  in  both. 

The  obstruction  which  produces  this  serious  condition  is  congenital 
in  about  one-third  of  the  cases.  A  stone  impacted  in  the  ureter  is 
responsible  for  about  40  per  cent,  of  acute  cases,  and  is  one  of  the 
serious  results  of  renal  calculus.  Sometimes  the  pedicle  of  a  movable 
kidney  becomes  twisted  and  obstruction  in  the  ureter  is  complete. 
Growths  in  the  bladder,  tumors  pressing  upon  the  ureter,  enlarged 
prostate,  and  pregnancy  are  also  entitled  to  places  on  the  list  of 
causes.  It  is  a  curious  fact  that  frequent  micturition  of  itself  is  a 
sufficient  cause  of  hydronephrosis.  This  is  how  it  happens  :  Every 
time  the  bladder  contracts  the  ends  of  the  ureters  which  pass  obliquely 
into  the  bladder  are  compressed  and  the  flow  of  urine  is  obstructed. 
Stone  in  the  bladder  causes  oft-repeated  contractions  and  is  a  common 
cause  of  hydronephrosis. 

SvJnptoins. — There  are  two  leading  symptoms  of  hydronephrosis  : 
I.  The  formation  of  a  tumor  in  the  loin  or  abdomen,  increasing  rapidly 
and  fluctuating.  2.  An  excessive  flow  of  urine,  followed  by  subsidence 
of  the  tumor.  This  is  pathognomonic.  It  is  seldom,  however,  that 
these  two  .symptoms  are  found  together.  The  tumor,  when  it  is  appa- 
rent, varies  greatly  in  size.  In  one  case  examined  post-mortem  by 
Glass  the  right  kidney  formed  a  tumor  which  so  distended  the  abdo- 


364  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

men  that  it  measured  six  feet  four  inches  in  circumference,  and  from 
the  ensiform  cartilage  to  the  pubis  it  measured  four  feet  and  half  an 
inch.  The  fluid  contained  in  the  cystic  kidney  measured  thirty  gallons 
and  was  of  a  light  coffee-color.  The  tumor  is  sometimes  irregular  or 
lobulated,  and  fluctuation  may  be  felt.  Without  a  tumor  there  are  no 
s\-mptonis  which  are  distinctive  of  hydronephrosis.  Sometimes  hydro- 
nephrosis is  intermittent,  the  tumor  at  one  time  being  tense  and  at 
another  soft  and  easily  compressed,  and  if  care  be  taken  to  measure 
the  urine,  the  amount  voided  will  be  found  to  be  increased  with  each 
subsidence  of  the  tumor. 

The  character  of  the  urine  is  of  no  value  in  diagnosis  when  only 
one  kidney  is  involved,  for  the  healthy  kidney  is  capable  of  keeping  up 
the  normal  character  of  the  excretion.  The  fluid  in  the  affected  kidney 
is  a  very  dilute  urine,  having  a  specific  gravity  of  about  1002,  and 
containing  the  natural  constituents  in  small  amounts. 

When  both  kidneys  are  affected  the  condition  is  serious  and  may 
lead  to  uremic  poisoning.  The  diagnosis  in  the  case  of  a  tumor 
forming  in  both  loins  can  be  settled  by  aspirating  one  or  other  kidney. 

The  danger  of  hydronephrosis  is  destruction  of  the  affected  kidney, 
the  constant  pressure  producing  absorption  of  the  excreting  part  of  the 
renal  substance,  and  eventually  converting  the  whole  organ  into  a 
fibrous  sac  containing  fluid.  When  only  one  organ  is  affected,  the 
opposite  one  often  proves  equal  to  the  requirements  of  both,  and  the 
full  amount  of  urine  is  excreted. 

The  diagnosis  must  be  made  between  hydronephrosis  on  the  one 
hand  and  ovarian  cyst,  ascites,  and  hydatids  on  the  other.  On  palpa- 
tion and  percussion  a  dilated  kidney  has  the  colon  in  front  of  the  swell- 
ing, and  there  is  dulness  in  the  lumbar  region.  -An  ovarian  cyst  can  be 
palpated  by  the  vagina,  and  has  its  dulness  in  the  middle  line,  gradually 
growing  from  the  pelvis.  In  ascites  the  patient  is  like  a  rubber  water- 
bag,  the  level  of  the  fluid  varying  with  change  of  position.  Hydatids 
cause  a  painless,  slowly-growing  tumor,  in  rare  instances  having  the 
hydatid  fremitus,  and  definitely  determined  by  the  presence  of  vesicles 
in  the  urine. 

Treatment. — WHien  there  is  evidence  of  obstruction  of  the  ureter 
either  by  a  calculus  or  other  foreign  body  an  attempt  may  be  made  to 
facilitate  its  passage  toward  the  bladder  by  massage  of  the  loin.  The 
injection  of  water  into  the  bladder  to  fully  distend  it  has  occasionally 
proved  of  assistance  in  favoring  the  release  of  a  calculus  down  the 
ureter  (Reghiald  Harrison).  Failing  in  these  measures,  the  next  effort 
should  be  to  relieve  the  symptoms  by  aspirating  the  tumor.  In  some 
cases  this  has  not  only  given  immediate  relief,  but  effected  a  permanent 
cure.  If  repeated  aspirations  prove  unavailing,  the  next  question  to 
take  into  consideration  is  the  opening  and  drainage  of  the  kidney.  The 
operation  consists  in  a  lumbar  incision  with  an  opening  into  the  kidney, 
and  the  establishment  of  drainage  until  the  sac  consolidates  or  becomes 
a  harmless  sinus.  This  is  preferable  to  nephrectomy,  which  has  also 
been  resorted  to  by  some  surgeons  as  a  remedy  for  hydronephrosis. 

Pyonephrosis. — Just  as  water  in  the  pleural  cavity  may  be  changed 
to  pus,  so  a  hydronephrosis  may  become  a  collection  of  purulent  matter ; 
or  if,  during  the  course  of  a  pyelitis,  obstruction  of  the  ureter  takes 


THE    GENITO-URINARY  SYSTEM.  365 

place,  the  secretion  of  pus  gradually  distends  the  kidney  till  it  reaches 
the  dimensions  and  character  described  under  Hydronephrosis.  The 
symptoms  are  practically  the  same.  When  a  diminution  in  the  size  of 
the  tumor  takes  place  the  excreted  fluid  is  found  to  be  pus. 

Tuberculosis  of  the  Kidney. — Tuberculosis  of  the  kidney  is  to 
be  suspected  when  chronic  renal  symptoms  exist,  combined  with  a 
family  history  of  tubercular  disease.  Males  form  a  large  majority  of 
the  patients,  and  the  most  susceptible  period  of  life  is  during  early 
adolescence  and  while  the  sexual  functions  are  most  active.  One 
reason  of  this  distinction  is  the  important  part  which  gonorrhea  plays 
in  the  causation.  The  female  when  the  subject  of  gonorrhea  is  more 
readily  cured,  and  is  not  so  liable  to  complications  as  the  male,  and 
when  the  tubercle  bacillus  attacks  women  it  shows  a  decided  preference 
for  the  lungs.  In  males  a  gonorrheal  orchitis  is  almost  a  constant  fore- 
runner of  renal  tuberculosis,  and  while  it  occasionally  happens  that  the 
tubercular  process  begins  in  the  kidney  and  makes  its  way  downward, 
the  opposite  direction  from  testicle  to  kidney  is  the  rule. 

Symptovis. — The  patient  is  generally  a  male  below  middle  age, 
having  a  family  history  of  tuberculosis  and  frequently  the  subject  of  a 
chronic  orchitis.  With  these  data  to  start  from,  the  symptoms  of  tuber- 
culosis in  the  kidney  bear  a  close  analogy  to  those  manifested  by  the 
disease  in  the  lung.  There  are  hematuria,  corresponding  to  hemopty- 
sis ;  irritation  in  the  urinary  tract,  causing  frequent  micturition,  corre- 
sponding to  cough  ;  and  increase  in  the  quantity  and  change  in  the 
character  of  the  mucus,  corresponding  to  expectoration  in  phthisis. 

Although  hematuria  can  occur  in  the  early  stage  of  the  disease,  it  is 
after  ulceration  has  been  established  that  it  appears  in  its  most  marked 
form.  Frequent  micturition  in  children  leads  to  a  suspicion  of  stone  in 
the  bladder,  and  this  source  of  error  must  be  guarded  against.  As 
the  disease  advances  the  excess  of  mucus  undergoes  a  change,  and 
the  urine  is  found  to  contain  considerable  quantities  of  pus. 

The  thermometer  is  valuable  here  as  in  the  diagnosis  of  pulmonary 
tuberculosis,  a  persistently  high  temperature  in  the  latter  part  of  the 
day  being  very  characteristic.  The  demonstration  of  the  bacilli  in  the 
urine  settles  the  diagnosis  beyond  question. 

Treatmetit. — The  general  treatment  as  regards  diet,  climate,  and 
hygiene  are  the  same  as  indicated  in  pulmonary  tuberculosis.  The 
local  treatment  involves  some  serious  considerations.  When  the  tes- 
ticle is  tuberculous,  the  gland  should  be  treated  as  any  other  tuber- 
culous gland.  If  there  be  no  evidence  of  the  disease  in  any  other  part 
of  the  body,  the  cheesy  masses  should  be  removed  or  the  testicle 
completely  excised.  The  bladder  requires  close  attention,  especially 
when  the  urine  is  offensive.  Injections  of  a  weak  solution  of  nitrate 
of  silver,  preceded  and  followed  by  irrigation,  is  one  of  the  best 
methods  of  disinfection.  Reginald  Harrison  recommends  Iodoform 
suspended  in  mucilage  in  the  proportion  of  five  grains  to  the  ounce. 
Nephrotomy  or  nephrectomy  cannot  be  recommended,  for  the  disease  is 
seldom  confined  to  one  kidney  or  to  any  one  portion  of  the  urinary 
tract. 

Hydatid  Cysts. — The  kidney  is  much  less  frequently  affected  by 
hydatids  than  the  lungs  or  the  liver.     In  the  majority  of  cases  the  left 


366  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

kidney  is  the  seat  of  the  parasites,  and  males  suffer  more  frequently 
than  females.  The  cyst  begins,  as  a  rule,  in  the  secreting  substance, 
but  occasionally  in  the  cellular  tissue  beneath  the  capsule  or  surround- 
ing the  pelvis.  Small  portions  of  the  contents  frequently  escape 
through  the  ureter,  and  it  is  probably  on  this  account  that  hydatid 
cysts  of  the  kidney  seldom  attain  to  large  size.  Rupture  is  not 
uncommon,  and  the  discharge  may  take  place  into  the  intestine  or 
lung,  but  never  externally  through  the  loin.  Sometimes  the  cyst 
undergoes  inflammatory  or  absorptive  changes,  as  happens  in  hydatids 
of  other  organs. 

Syviptonis. — When  the  tumor  is  small  a  hydatid  cyst  of  the  kidney 
may  present  no  symptoms,  and  in  the  favorable  cases  in  which  it  dis- 
charges through  the  ureter  the  disease  may  undergo  a  spontaneous 
cure  without  recognition.  In  many  cases  (52  out  of  63,  according  to 
Roberts)  vesicles  are  passed  in  the  urine  and  afford  the  first  clue  to  the 
nature  of  the  affection.  In  their  journey  down  the  ureter  these 
vesicles  produce  well-marked  attacks  of  renal  colic,  and  occasionally 
hydronephrosis.  The  tumor  in  the  loin  is  smooth,  but  seldom  is 
fluctuation  elicited.  When  the  vesicles  get  into  the  bladder  they 
may  produce  irritation  and  tenesmus ;  in  the  urethra  they  may 
cause  retention  of  urine.  In  any  case  inflammation  and  suppuration 
may  supervene,  while  blood  and  pus  escape  with  the  urine.  The 
hydatid  fremitus  so  constantly  mentioned  as  a  diagnostic  sign  is  really 
of  little  value,  owing  to  the  extreme  rarity  with  which  it  can  be 
detected.  To  settle  positively  the  diagnosis,  exploratory  puncture  is  a 
proper  measure,  the  demonstration  of  the  booklets  under  the  micro- 
scope leaving  no  possible  room  for  doubt.  It  must,  however,  be 
borne  in  mind  that  exploratory  puncture  is  not  devoid  of  danger. 
When  it  is  necessary  to  resort  to  it  the  surgeon  should  be  prepared  to 
operate  the  moment  the  diagnosis  is  settled. 

Treatment. — The  surgical  treatment  is  the  same  as  that  indicated  for 
hydatids  of  the  liver.  An  incision  as  for  nephrorrhaphy  is  made  in  the 
loin,  the  cyst  freely  opened,  its  edges  stitched  to  the  external  wound, 
and  the  ca\'ity  cleaned  out  and  drained. 

Simple  Cysts. — Serous  cysts  springing  from  the  renal  cortex  are 
recognized  on  palpation  as  thin-walled  globular  tumors.  Their  con- 
tents vary  from  a  thick  jelly-like  substance  to  a  thin,  straw-colored 
fluid  containing  albumin,  cholesterin,  and  sometimes  blood. 

There  are  few  symptoms  to  aid  the  examiner  except  a  painless, 
smooth  tumor  in  the  loin,  growing  slowly  and  producing  neither  dis- 
turbance of  the  general  health  nor  derangement  of  the  urinary  organs. 
The  diagnosis  must  rest  upon  the  exclusion  of  other  tumors  of  the 
kidney  of  a  cystic  nature. 

Solid  Tumors. — Before  five  years  of  age  and  after  thirty  solid 
tumors  of  the  kidney  are  not  uncommon.  No  matter  how  fine  the 
distinctions  made  by  the  pathologists,  or  how  exhaustiv^e  the  classi- 
fication adopted  by  the  clinician,  tumors  will  always  fall  under  one  of 
two  great  classes — benign  and  malignant.  In  the  kidney  benign  solid 
tumors  are  almost  never  found.  When  you  make  a  diagnosis  of  solid 
tumor  it  is  equivalent  to  saying  that  the  growth  is  either  a  sarcoma  or 
a  carcinoma.     For  the  sake  of  being  systematic  we  adopt  a  classifica- 


THE    GENITO-URINARY  SYSTEM. 


367 


tion  of  renal  tumors,  and  that  of  Paul  seems  to  be  the  simplest  and  is 
sufficiently  comprehensive  : 

Of  congenital  origin  :  Sarcoma,  hydronephrosis,  cavernous  tumors, 
dermoid  tumors. 

Of  adult  origin  :  Cystic  disease,  cavernous  tumors,  sarcoma,  adenoma, 
carcinoma. 

Syuiptoms  of  Solid  Tumors. — In  examining  a  tumor  in  the  lumbar 
region  the  following  points  require  attention  :  A  kidney  as  it  enlarges 
takes  a  direction  forward,  while  an  abscess  or  other  lesion  which  can 
simulate  an  enlarged  kidney  causes  bulging  posteriorly.  A  kidney  is 
always  round,  and  can  thus  be  distinguished  from  the  liver,  which  has 
a  sharp  edge,  and  from  the  spleen,  which  has  a  characteristic  notch. 


Fig.  156. — Carcinoma  of  the  kidney  from  a  patient  aged  eighty.  Patient  made  a  good 
recovery  from  the  operation,  but  died  two  months  later  of  persistent  vomiting  and  dilated 
stomach  (from  a  photograph  in  the  collection  of  Dr.  Andrews,  Mankato). 

The  kidney  does  not  rise  and  fall  with  the  respiratory  movements  as 
freely  as  does  the  liver.  A  tumor  of  the  kidney  has  usually  a  resonant 
zone  in  front  of  it,  which  is  the  ascending  or  descending  colon.  This 
may  be  absent,  owing  to  congenital  malposition  of  the  colon.  When 
the  intestine  fails  to  give  resonance  on  percussion,  the  bowel  can  some- 
times be  felt  as  a  cord-like  structure  between  the  tumor  and  the  skin. 
Briefly  stated,  the  distinctive  symptoms  of  cancer  of  the  kidney  are  a 
tumor  in  the  lumbar  region  and  hematuria  (Fig.  156).  The  tumor 
grows  in  the  direction  of  least  resistance,  which  is  forward,  and  over- 
lying it  is  the  colon  recognized  by  a  zone  of  resonance.  From  tumors 
of  the  liver  a  renal  growth  is  distinguished  by  the  following  points : 


368  SCKGICAL    DIAGXOSIS   A  .YD    TREATMENT. 

1.  The  liver  rises  and  falls  with  respiration. 

2.  Hepatic  tumors  have  no  bowel-resonance  in  front. 

3.  The  sharp  edge  of  the  liver  can  frc(]iu;ntl\' be  felt;  kidney  tumors 
are  always  round. 

4.  Between  a  renal  tumor  and  the  edge  of  the  ribs  is  a  space  into 
which  the  fingers  can  be  pushed. 

Between  a  splenic  and  a  renal  tumor  the  differences  are — 

1.  A  splenic  tumor  has  no  bowel  in  front. 

2.  It  has  usually  a  well-defined  edge,  and  sometimes  a  notch  can 
be  felt. 

Hematuria  is  found  in  about  half  the  cases.  It  may  occur  at  any 
stage  of  the  disease,  and  is  generally  intermittent.  When  the  amount 
of  blood  is  large  it  may  form  clots  in  the  ureter  or  bladder,  and  then 
renal  colic  or  vesical  tenesmus  becomes  a  prominent  symptom.  In  the 
intervals  between  attacks  of  hematuria  the  urine  is  normal  or  it  may 
contain  pus-  or  tube-casts. 

Pressure-symptoms  are  sometimes  prominent.  One  or  both  legs 
may  be  edematous,  and  large  veins  may  course  over  the  abdominal 
wall ;  the  bladder  may  be  irritable  and  the  bowels  constipated. 

Pain  is  not  a  constant  symptom,  but  in  a  majority  of  cases  it  is  pro- 
nounced. It  is  most  prominent  in  the  loin  and  abdomen,  but  is  reflected 
down  the  thigh  and  around  the  back  and  shoulders. 

Treatment. — All  congenital  solid  tumors  of  the  kidney  must  be  con- 
sidered malignant,  and  therefore  the  treatment  is  by  no  means  hopeful. 
Internal  remedies,  such  as  iodid  of  potassium  and  Chian  turpentine, 
have  given  some  encouragement.  When  improvement  appeared  to 
take  place  it  was  only  temporary.  The  toxins  of  er>'sipelas  and 
bacillus  prodigiosus  enjoyed  a  reputation  for  a  time,  and  several  cases 
of  sarcoma  were  reported  as  cured  by  their  use.  A  most  patient  trial 
in  three  cases  of  my  own  ended  in  utter  disappointment. 

The  question  of  removal  of  the  growth,  including  the  kidney,  is  a 
most  serious  one.  Of  35  operations  reported  by  Mr.  Sutton  for  renal 
sarcoma  in  children  under  six  years  of  age,  15  recovered,  but  all  died 
within  a  year  from  recurrence  of  the  growth.  If  recognized  at  an  early 
period  of  the  disease,  extirpation  would  give  a  chance  of  future  im- 
munity, and  several  cases  are  recorded  in  which  the  patients  remained 
free  from  recurrence  at  the  end  of  two  or  three  years.  In  adults,  when 
urgent  symptoms  such  as  profuse  hematuria  or  intense  pain  call  loudly 
for  relief,  operation  may  afford  the  only  prospect,  but  the  possibility  of 
cure  is  so  remote  that  the  brightest  side  that  can  be  claimed  for  the 
operation  is  that  it  is  likely  to  end  the  patient's  suffering  by  an  easy 
death. 

II.   INJURIES   AND   DISEASES   OF  THE   URETER. 

Surgical  Anatomy. — The  ureter  is  a  muscular  canal  which  carries 
the  urine  from  the  pelvis  of  the  kidney  to  the  bladder.  Its  average 
diameter  is  one-eighth  to  one-sixth  of  an  inch,  and  its  length  from 
ten  to  thirteen  inches.  Its  walls  consist  of  three  coats.  The  outer 
is  composed  of  connective  tissue  with  elastic  fibers ;  the  middle  coat  is 
muscular,  the  fibers  being;  both  longitudinal  and  circular;  the  inner 


THE    GENITO-URINARY  SYSTEM.  369 

coat  is  composed  of  mucous  membrane.  The  ureter  lies  behind  the 
peritoneum,  but  bound  to  that  membrane  by  fibrous  bands,  so  that 
when  the  peritoneum  is  stripped  from  the  parts  behind  the  ureter 
always  follows  it.  On  this  account  the  ureter  is  difficult  to  find  in  the 
bottom  of  a  deep  lumbar  wound,  especially  in  fat  subjects. 

Its  course  is  downward  from  the  kidney,  at  first  lying  on  the  psoas 
muscle,  and  then  crossing  the  bifurcation  of  the  common  iliac  arteries. 
Although  nearly  straight,  the  tube  really  takes  two  curves — the  first 
from  the  kidney  to  the  brim  of  the  pelvis,  its  convexity  toward  the  middle 
line ;  the  second  or  pelvic  curve  has  its  convexity  directed  toward  the 
outer  wall  of  the  pelvis.  The  ureters  enter  the  neck  of  the  bladder 
about  two  inches  apart,  running  obliquely  between  the  muscular  and 
mucous  coats  for  a  distance  of  a  half  or  three-quarters  of  an  inch.  In 
the  male  this  opening  is  external  to  the  vas  deferens ;  in  the  female  the 
ureter  penetrates  the  plexus  of  veins  beneath  the  broad  ligament. 

The  canal  is  not  absolutely  uniform  in  caliber  throughout  its  entire 
course ;  Halle  and  Tanguery  have  shown  that  in  normal  subjects  it  is 
narrowed  in  three  places — viz.  {a)  At  a  point  between  one  and  a  half 
and  two  and  a  half  inches  from  the  pelvis  of  the  kidney ;  {d)  at  the 
junction  of  the  pelvis  and  vesical  portions ;  and  (r)  at  the  place  where 
it  crosses  the  iliac  artery.  These  are  the  localities  where  small  stones 
from  the  kidney  have  been  found  to  be  arrested  (Fenger). 

In  palpating  the  ureter  the  following  landmarks  from  Tourneur  are 
of  importance:  At  the  junction  of  the  internal  with  the  middle  third 
of  Poupart's  ligament  erect  a  vertical  line.  This  line  corresponds  with 
the  course  of  the  abdominal  portion  of  the  ureter.  It  crosses  the  brim 
of  the  pelvis  four  and  a  half  centimeters  from  the  middle  line.  This 
point  is  found  by  drawing  a  horizontal  line  from  one  anterior  superior 
iliac  spine  to  the  other,  and  intersecting  this  by  a  vertical  line  through 
the  pubic  spine.  At  the  point  of  intersection  gentle  steady  pressure  can 
be  made  by  the  fingers  until  the  brim  of  the  pelvis  is  reached.  Tender- 
ness or  dilatation  of  the  ureter  at  this  point  can  thus  be  detected.  The 
vesical  portion  of  the  ureter  can  be  palpated  through  the  rectum  in  the 
male.  When  a  stone  is  lodged  in  the  ureter,  even  at  a  point  high  up, 
exquisite  sensitiveness  is  experienced  in  this  examination  (Guyon,  cited 
by  Fenger).  In  females  the  ureter  can  be  palpated  through  the  vagina 
for  a  distance  of  two  or  three  inches  as  it  runs  in  the  broad  ligament 
close  to  the  upper  wall  of  the  vagina  (Cabot). 

Rupture  of  the  Ureter. — It  would  seem  almost  impossible  that 
the  ureter  should  suffer  injury,  protected  as  it  is  by  strong  masses  of 
muscle  and  fat  and  guarded  by  promontories  of  bone.  When  rupture 
does  occur,  it  is  by  the  application  of  very  great  violence  to  the  trunk 
or  abdominal  region.  The  kick  of  a  horse,  the  passage  over  the  body 
of  a  heavily-laden  wagon,  a  blow  from  the  handle  of  a  wheelbarrow, 
violent  over-stretching,  and  other  traumatisms  have  been  reported  as 
causes. 

Symptoms. — The  symptoms  are  generally  obscure,  and  often  they 
are  long  delayed.  When  the  bladder  or  the  kidney  is  ruptured,  the 
symptoms  are  prompt  in  making  their  appearance.  Not  so  with  the 
ureter,  for  at  the  beginning  there  are  no  grave  symptoms  unless  some 
other  important  organs  are  injured. 

24 


370  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

When  there  is  an  external  wound  through  which  urine  is  found  to 
escape  the  diagnosis  is  positive.  In  the  absence  of  this  sign  the  evi- 
dence must  rest  hirgely  on  the  nature  and  severity  of  the  injury.  In 
some  cases  the  urine  is  bloodstained.  A  swelling  in  the  loins  and  a 
collection  of  fluid,  which  when  drawn  off  by  the  aspirator  is  found  to 
resemble  urine,  are  very  suggestive  of  rupture.  This  swelling  does  not 
occur  until  some  time  after  the  receipt  of  the  injury.  The  time  varies 
from  seven  days  to  seven  wrecks.  The  swelling  is  round,  oblong,  or 
sausage-shaped,  following  the  course  of  the  canal,  and  is  paljiable  from 
the  abdomen  (Fcnger). 

The  fluid  which  produces  the  swelling  just  mentioned  is  not  pure 
urine,  nor  is  the  rupture  of  a  ureter  followed  by  extravasation  of  urine, 
as  we  would  naturally  infer.  The  clinical  fact  remains  that  in  cases  of 
ruptured  ureter  a  fluid  is  poured  out  at  the  seat  of  rupture  which  is  not 
productive  of  the  disastrous  consequences  which  follow  extravasation 
of  urine  in  other  parts.  When  extravasation  of  urine  takes  place  in 
the  scrotum  or  perineum  from  ruptured  urethra,  inflammatory  symp- 
toms soon  appear  and  rapidly  proceed  to  gangrene  of  the  parts 
involved.  In  rupture  of  the  ureter  a  swelling  forms  and  continues  for 
days  or  weeks  without  any  inflammation  or  gangrene.  In  explanation 
of  this  singular  condition  Reginald  Harrison  suggests  that  the  rupture 
of  the  ureter  is  followed  by  the  formation  of  clots,  not  only  in  the 
ureter,  but  in  the  corresponding  kidney ;  that  these  ante-mortem  clots 
are  a  provision  for  the  substitution  of  a  kind  of  urine  which  is  incapable 
of  proving  destructive  to  the  tissues  with  which  it  may  come  in  con- 
tact. In  a  case  of  his  own  he  was  able  to  examine  this  kind  of  urine, 
and  found  that  there  w^as  almost  a  complete  absence  of 'urea.  There 
being  no  urea  to  decompose,  there  is  no  source  for  the  production  of 
the  ammonia  by  which  the  destruction  of  tissues  is  eflected  when  nor- 
mal urine  is  extravasated.  The  absence  of  urea  renders  the  urine 
chemically  harmless  to  the  tissues  with  which  it  comes  in  contact. 

One  of  the  consequences  of  ruptured  ureter  is  the  formation  of 
dense  and  unyielding  strictures.  As  a  consequence  of  stricture  the 
kidney  may  suffer  from  hydronephrosis  and  undergo  atrophy. 

Treatment. — If  an  early  diagnosis  can  be  made  (and  this  is  only 
possible  when  there  is  a  wound  through  which  urine  is  trickling),  the 
proper  treatment  of  ruptured  ureter  would  be  to  enlarge  the  incision, 
find  the  divided  ends  of  the  tube,  and  unite  them  in  the  manner  which 
will  be  presently  described.  So  far,  this  has  not  been  attempted.  In 
the  majority  of  cases  the  diagnosis  is  arrived  at  after  the  formation  of 
a  swelling  due  to  a  collection  of  modified  urine  above  described.  The 
treatment  in  vogue  for  this  condition  is  puncture  or  incision,  and  drain- 
age either  through  the  abdominal  cavity  or  by  a  lumbar  incision. 
Nephrectomy  has  been  resorted  to  in  a  number  of  these  cases  and  in 
accidental  division  of  the  ureter  during  celiotomies. 

Nephrectomy  is  too  radical  an  operation  to  be  thought  of  before 
every  other  expedient  has  been  tried  to  restore  the  function  of  a  rup- 
tured or  severed  ureter.  Instead  of  proceeding  deliberately  to  remove 
the  kidney,  an  exploratory  incision  would  be  the  proper  course.  Search 
should  be  made  for  the  ends  of  the  ureter,  and  if  found  an  attempt 
should  be  made  to  unite  them.     Access  to  the  ureter  can  be  had  by 


THE    GENITO-URTNARY  SYSTEM.  37 1 

the  abdominal  or  by  the  lumbar  incision.  An  incision  in  the  middle 
line  or  a  little  to  one  side  exposes  the  whole  length  of  the  ureter  with 
little  difficulty,  but  the  operation  is  intra-peritoneal,  and  unless  the  urine 
is  aseptic  the  danger  of  peritonitis  is  great.  The  lumbar  incision  ren- 
ders it  more  difficult  to  reach  the  ureter,  owing  to  the  depth  of  the 
wound,  but  when  it  is  practicable  it  should  be  chosen  as  much  the 
safer  operation.  The  incision  begins  at  the  lower  border  of  the  twelfth 
rib,  at  the  edge  of  the  erector  spinae  muscle,  and  extends  along  a  line 
one  inch  anterior  to  the  ilium,  and  thence  along  Ponpart's  ligament  to 
about  its  middle.  Only  the  upper  two-thirds  of  the  ureter  can  be  ex- 
posed by  this  procedure. 

Van  Hook's  method  of  suturing  the  divided  ureter  (uretero-ureter- 
ostomy)  is  as  follows:  i.  "  Ligate  the  lower  portion  of  the  tube  one- 
eighth  or  one-fourth  of  an  inch  from  the  free  end.  Silk  or  catgut 
may  be  used.  Make  with  fine  sharp-pointed  scissors  a  longitudinal 
incision  twice  as  long  as  the  diameter  of  the  ureter  in  the  wall  of  the 
lower  end  one-fourth  of  an  inch  below  the  ligature. 

2.  "  Make  an  incision  with  the  scissors  in  the  upper  portion  of  the 
ureter,  beginning  at  the  open  end  of  the  duct  and  carrying  it  up  one- 
fourth  of  an  inch.     This  incision  ensures  the  patency  of  the  tube. 

3.  "  Pass  two  very  small  cambric  sewing-needles,  armed  with  one 
thread  of  sterilized  catgut,  through  the  wall  of  the  upper  end  of  the 
ureter  one-eighth  of  an  inch  from  the  extremity,  from  within  outward, 
the  needles  being  from  one-sixteenth  to  one-eighth  of  an  inch  apart 
and  equidistant  from  the  end  of  the  duct.  It  will  be  seen  that  the 
loop  of  catgut  between  the  needles  firmly  grasps  the  upper  end  of 
the  ureter. 

4.  "  These  needles  are  now  carried  through  the  slit  in  the  side  of  the 
lower  end  of  the  ureter  into  and  down  the  tube  for  half  an  inch,  where 
they  are  passed  through  the  wall  of  the  duct  side  by  side. 

5.  "It  will  now  be  seen  that  the  traction  upon  the  catgut  loop  passing 
through  the  wall  of  the  ureter  will  draw  the  upper  fragment  of  the  duct 
into  the  lower  portion.  This  being  done,  the  ends  of  the  loop  are  tied 
together  securely,  and,  as  the  catgut  will  be  absorbed  in  a  few  days, 
calculi  do  not  form  to  obstruct  the   passage  of  the  urine. 

6.  "  The  ureter  is  now  enveloped  carefully  with  peritoneum,  as 
already  described  in  other  operations,  provided  an  intra-peritoneal 
operation  has  been  done." 

As  an  additional  security  against  leakage  Bloodgood  recommends  the 
application  of  two  sutures  through  the  external  coats  (Figs.  1 57-161). 

Another  method  of  dealing  with  a  divided  ureter  is  b)'  ituplantatioii. 
When  there  is  loss  of  substance  or  when  from  any  cause  the  ends  of 
the  tube  cannot  be  approximated,  the  following  expedients  have  been 
resorted  to : 

1.  Implantation  of  the  proximal  end  of  the  ureter  into  a  loop  of 
intestine.  This  is  objectionable  on  account  of  the  risk  of  septic 
infection  of  the   kidney  by  the  gases  escaping  from  the  bowel. 

2.  Implantation  into  the  bladder.  When  the  proximal  end  of  the 
ureter  is  long  enough  to  reach  the  bladder,  this  procedure  is  better 
than  any  other,  as  it  re-establishes  the  natural  course  of  the  urine  and 
is  free  from  danger  of  septic  infection. 


372 


SURGICAL  DIAGNOSIS  AND    TREATMENT. 


Fl>..  1-,/. — L  itifio-urfterectomy  (Van  Hook's  method).  The  needles  have  been  introduced 
into  the  wall  of  the  renal  portion  of  the  ureter.  The  end  of  the  vesical  portion  of  the  tube  has 
been  ligated  and  a  slit  made  in  its  wall. 


Fig.  158. — The  needles  carrying  the  traction  suture  attached  to  the  renal  portion  of  the 
ureter  have  been  passed  into  the  slit  in  the  wall  of  the  vesical  portion,  carried  down  a  short 
distance,  and  pushed  out  through  the  wall. 


Fig.  159. — By  means  of  the  traction  suture  the  renal  portion  of  the  ureter  has  been  implanted 
into  the  vesical  portion.     The  ends  of  the  traction  suture  have  been  tied  together. 


Fig.  160. — Ureter  anastomosed 


traction  sutures  tied ;  and  two  fi.xation  sutures  in  place  ready 
to  be  tied. 


Fig.  161. — Longitudinal  section  of  ureter,  showing  new  lumen  and  diverticulum. 

3.  Implantation  into  the  pelvis  of  the  kidney.     This  is  applicable  to 
cases  in  which  the  division  is  at  the  upper  portion  of  the  ureter. 

4.  Implantation  through  the  skin.     When  the  ureter  is  divided  in 


THE    GENITO-URINARY  SYSTEM.  373 

the  pelvis  and  cannot  be  connected  with  the  bladder  and  vagina,  it  has 
been  suggested  by  Van  Hook  to  attach  the  proximal  end  by  sutures 
to  an  opening  in  the  skin. 

Ureteral  Calculus. — A  stone  in  the  ureter  is  likely  to  be  arrested 
at  one  or  other  of  three  portions  of  the  tubes  which  are  naturally  nar- 
rowed— that  is  to  say,  at  a  point  between  one  and  a  half  and  two  and 
a  half  inches  from  the  pelvis  of  the  kidney,  at  the  junction  of  the  pelvic 
and  vesical  portions,  and  at  the  point  where  the  ureter  crosses  the  iliac 
artery.  Of  these  three  portions,  the  upper  is  most  frequently  the 
lodging-place  of  a  calculus,  while  stone  is  found  in  about  equal 
frequency  in  the  two  lower  portions. 

Diagnosis. — The  diagnosis  of  stone  in  the  ureter  is  only  possible  in 
that  portion  of  the  duct  which  can  be  palpated  from  the  rectum  or 
vagina.  Even  when  thus  favorably  located  errors  in  diagnosis  are  apt 
to  occur.  A  calculus  palpated  from  the  vagina  is  likely  to  be  mistaken 
for  a  diseased  ovary,  as  happened  in  Collingworth's  case.  The  symp- 
toms of  stone  in  the  upper  portion  of  the  ureter  are  those  of  stone  in 
the  kidney,  and  a  differential  diagnosis  is  impossible. 

Removal  of  stones  from  the  ureter  is  effected  by  different  methods 
according  to  their  location : 

1.  Longitudinal  Ureterotomy. — When  the  calculus  is  lodged  in  the 
upper  part  of  the  ureter  an  attempt  should  be  made  to  push  it  back  into 
the  renal  pelvis,  whence  it  can  be  withdrawn  through  an  incision  in  the 
renal  tissue.  Failing  in  this,  an  incision  should  be  made  in  the  long 
axis  of  the  ureter  over  the  stone.  The  wound  in  the  ureter  is  care- 
fully closed  with  sutures  if  the  operation  is  intra-peritoneal.  When 
extra-peritoneal  no  sutures  are  required,  as  the  urine  can  be  drained 
until  the  wound  closes  by  granulation. 

The  consequences  of  obstruction  with  calculi  of  one  or  both  ureters 
are  serious.  When  one  tube  only  is  obstructed,  absorption  and  dis- 
integration of  the  corresponding  kidney  take  place.  When  both  tubes 
are  occluded,  speedy  death  results  from  mechanical  suppression  of 
urine. 

2.  Ureterotomy  through  the  Vagina. — When  by  palpation  a  stone 
can  be  felt  in  the  lower  end  of  the  ureter,  its  removal  by  way  of  the 
vagina  may  be  accomplished  without  great  difficulty.  The  usual  posi- 
tion of  the  calculus  is  in  the  broad  ligament  close  to  the  cervix  uteri. 
The  incision  is  best  made  with  scissors,  and  the  wound  can  be  closed 
with  interrupted  sutures. 

3.  Removal  through  the  Rectum. 

4.  Removal  through  the  Bladder. — The  stone  may  be  so  near  the 
lower  end  of  the  ureter  as  to  give  a  click  when  examined  with  a  sound. 
In  this  case  the  urethra  is  dilated,  and  also  the  orifice  of  the  ureter  if 
necessary,  and  the  stone  withdrawn.  Whitehead  removed  eleven 
calculi  in  this  manner.  Sometimes  the  mucous  membrane  has  to  be 
divided  before  the  stone  can  be  set  free. 

Ureteritis. — Inflammation  of  the  ureter  is  probably  a  quite  com- 
mon condition,  but  masked  by  renal  and  vesical  diseases.  According 
to  Mann,  ureteritis  has  seven  causes:  (i)  injuries  during  childbirth; 
(2)  previous  disease  of  the  bladder ;  (3)  gonorrhea ;  (4)  suppuration 
of  the  pelvis  of  the  kidney  ;  (5)  pelvic  inflammations  and  tumors ;  (6) 


0/4 


SURGICAL    DIAGNOSIS  AND    TREATMENT. 


abnormal  conditions  of  the  urine;  (7)  tuberculosis.  The  pathological 
changes  produced  by  inflammation  are  in  some  cases  a  slight  swelling 
of  the  tubes  and  desquamation  of  the  epithelial  lining ;  in  others  a 
purulent  condition  indicating  ulceration  of  the  lining  membrane ;  in 
still  another  class  the  tube  is  thickened,  increasing  the  caliber  of  the 
ureter  to  the  size  of  a  lead-pencil  or  larger. 

Symptoms. — The  most  constant  symptoms  are  frequent  or  almost 
continuous  micturition  and  a  boring  pain  along  the  course  of  one  or 
both  ureters.  The  left  suffers  more  frequently  than  the  right.  The 
disease  is  usually  chronic  in  its  course,  and  great  depression  of  spirits 
is  not   uncommon. 

Treatment. — The  general  treatment  consists  in  securing  the  best 
hygienic  surroundings,  avoiding  alcoholic  and  other  irritating  bever- 
ages, and  paying  careful  attention  to  diet.  The  bowels  should  be  kept 
relaxed  and  alkalies  should  be  given  continuously.  For  improving  the 
condition  of  the  urine  copaiba,  oil  of  sandalwood,  and  benzoic  acid  are 
recommended. 

Local  applications  of  nitrate  of  silver  or  boracic  acid  may  be  made 
to  the  ureters  after  first  dilating  the  urethra  in  the  manner  recommended 
by  Simon,  Pawlik,  and  Kelly. 

Stricture  of  the  Ureter. — The  healing  of  a  wound  of  the  ureter 


>-yr-yO 


k:^ 


<^ 


Fig.  162. — Fenger's  plan  of  operating  for  ureteral  stricture  on  extra-peritoneal  surface  of 
ureter:  (^)  ureter  stricture  and  line  of  incision  ;  (i5)  opening  through  the  stricture  extending 
into  the  proximal  and  distal  portion  of  the  ureter,  the  extreme  ends  of  the  incision  a  and  a'  to 
be  united;  (C)  ureter  after  suturing;  a,  the  bend  at  the  site  of  the  stricture. 


is  likely  to  be  attended  with  the  formation  of  cicatricial  tissue,  which  by 
its  contraction  narrows  the  tube  in  the  same  manner  as  occurs  so  fre- 
quently in  the  male  urethra.     There  is  a  question  whether  stricture  can 


THE    GENITO-URINARY  SYSTEM.         •  IJ^ 

be  caused  by  gonorrheal  infection  spreading  from  the  urethra  to  the 
bladder  and  thence  to  the  ureter.  Tumors  in  the  pelvis  and  abdomen 
are  common  causes  of  obstruction  of  the  ureters. 

In  many  of  the  cases  stricture  results  from  the  healing  of  ulceration 
caused  by  the  temporary  obstruction  of  a  calculus  or  by  the  healing 
of  a  tubercular  abrasion. 

Operations  for  the  Relief  of  Stricture  of  the  Ureter. —  i.  Fenger's 
method  consists  in  making  a  longitudinal  incision  at  the  seat  of  stric- 
ture and  converting  it  by  sutures  into  a  transverse  incision.  The  ureter 
is  opened  above  or  below  the  stricture  and  the  incision  carried  through 
the  constricted  portion,  as  seen  in  Fig.  162.  The  upper  and  lower  ends 
of  the  longitudinal  wound  are  then  brought  together  by  folding  the 
ureter  upon  itself  The  remainder  of  the  wound  is  approximated  by 
sutures  which  catch  the  outer  and  middle  coats,  thus  converting  the 
longitudinal  into  a  transverse  wound  (Fig.    162). 

2.  Dilatation  by  bougies  has  been  successfully  practised  by  Alsbe'rg 
in  a  case  of  stricture  near  the  pelvis  of  the  kidney  attended  by  hydro- 
nephrosis. 

3.  Resection  of  the  ureter  and  implantation  of  the  distal  end  into 
the  pelvis  of  the  kidney. 

III.   INJURIES   AND   DISEASES  OF  THE   BLADDER. 

In  the  general  examination  of  a  patient  our  attention  is  usually 
drawn  to  the  bladder  by  one  or  more  of  the  following  symptoms — viz, 
pain,  frequent  micturition,  and  hematuria.  The  significance  of  these 
symptoms  we  shall  now  consider. 

Pain. — This  is  not  necessarily  felt  at  the  seat  of  the  disease,  but,  like 
the  pain  in  hip-disease,  may  be  felt  at  a  distance.  Stone  in  the  bladder 
produces  pain  on  the  under  surface  of  the  penis  a  little  behind  the 
meatus.  When  the  kidney  is  the  seat  of  the  disease,  pain  is  felt  in  the 
groin,  in  the  testicle,  and  down  the  thigh.  Disease  in  the  testicle  pro- 
duces pain  along  the  inguinal  line.  These  are  reflected  pains,  and  are 
felt  at  the  termination  of  the  nerve  and  not  at  the  spot  where  the  nerve 
is  irritated. 

Direct  pain,  however,  is  not  uncommon.  When  the  bladder  becomes 
over-distended  the  pain  is  felt  over  the  viscus  itself  Urethritis  causes 
pain  at  the  seat  of  the  inflammation,  which  is  always  accentuated  by 
external  pressure  at  that  point.  In  inflammation  of  the  prostate  the 
pain  is  most  marked  in  the  perineum  and  rectum,  and  is  greatly  in- 
creased by  digital  pressure  by  way  of  the  rectum.  Combined  with 
these  direct  we  may  also  have  indirect  pains  running  along  the  course 
of  the  urethra,  and  leading  us  to  suspect  the  presence  of  stone  in  the 
bladder. 

A  valuable  aid  to  diagnosis  is  a  consideration  of  the  time  at  which 
pain  is  felt.  If  it  is  felt  during  micturition,  we  naturally  suspect  inflam- 
mation in  the  urethra,  the  prostate,  or  the  bladder.  A  patient  with 
stone  in  the  bladder  complains  of  pain  at  the  end  of  micturition,  and 
well  he  may,  for  the  viscus,  after  expelling  all  the  urine,  violently  con- 
tracts upon  the  calculus  in  a  vain  but  painful  effort  to  get  rid  of  the 
foreign  body.     Pain  that  is  felt  before  the  act  of  micturition,  and  which 


376  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

ceases  after  tlie  act,  is  due  to  cystitis  or  to  retention  of  urine.  Pain 
durinL^  micturition,  <^reatly  aggravated  by  the  act  of  defecation,  is  an 
indication  of  inflammation  in  the  prostate. 

Frcijucnt  Micturition. — The  expulsion  of  urine  from  the  bladder  is  a 
reflex  act.  In  the  normal  condition  the  urine  trickling  down  the  ureters 
gradually  expands  the  bladder  till  a  certain  degree  of  irritation  is  applied 
to  the  terminal  branches  of  the  sensitive  nerves  which  supply  the  viscus. 
This  stimulus  runs  up  the  sensory  nerves  to  the  spinal  cord,  and  thence 
to  the  motor  nerves  which  supply  the  muscles  of  the  bladder  and  ure- 
thra. These  muscles  contract  and  empty  the  bladder.  Any  stimulus 
applied  to  the  terminal  branches  of  the  sensitive  nerves  will  produce 
the  same  result ;  consequently,  frequency  of  micturition  is  a  symptom 
of  cystitis,  urethritis,  or  prostatitis.  It  also  occurs  when  the  capacity 
of  the  bladder  is  lessened,  when  the  urine  undergoes  certain  changes, 
when  there  is  phimosis,  contracted  meatus,  stricture,  or  calculus.  Taken 
by  itself,  frequent  micturition  is  a  symptom  of  very  indefinite  signif- 
icance. When  it  is  met  with,  the  question  should  be  decided  as  to 
whether  it  is  increased  by  exercise  or  by  rest.  A  stone  or  a  tumor  in 
the  bladder  may  be  suspected  when  movement  increases  the  frequency ; 
atony  of  the  bladder  and  disease  of  the  prostate  are  to  be  suspected 
wl^en  the  frequency  of  urination  is  increased  by  rest.  The  size  and 
force  of  the  stream  should  be  carefully  noted.  A  small  stream  is 
caused  by  stricture,  by  a  contracted  meatus,  or  by  inflammatory 
swelling  in  some  part  of  the  urethra.  If  the  time  spent  in  the  act  of 
micturition  is  lengthened  and  the  force  of  the  current  is  slow,  obstruc- 
tion may  be  suspected,  the  most  common  causes  of  which  are  stricture, 
prostatic  disease,  and  muscular  atony. 

Hematuria. — Bleeding  may  occur  from  any  part  of  the  urinary  tract, 
and  by  close  observation  we  can  generally  locate  its  origin.  When  it 
comes  from  the  kidneys  it  is  well  mixed  with  the  urine,  giving  the  fluid 
a  smoky  appearance.  In  addition  there  is  a  history  of  renal  disease,  as 
indicated  by  albuminuria,  the  presence  of  granular  or  hyaline  casts, 
degeneration  of  the  retina,  etc.  The  color  alone  should  not  be  relied 
upon,  for  smoky  or  beef-tea-colored  urine  may  be  produced  when 
blood  in  small  quantities  escapes  from  the  bladder-wall  and  has  time 
to  mix  freely  with  the  urine  before  being  expelled.  Black  or  coffee- 
colored  blood  is  produced  by  profuse  hemorrhage  from  the  bladder 
accompanied  with  retention  from  clotting.  Blood  from  the  ureter  is  an 
accompaniment  of  renal  colic,  and  is  usually  due  to  the  passage  of  a 
calculus  on  its  way  from  the  kidney  to  the  bladder.  The  quantity  of 
blood  is  seldom  large,  but  the  terrible  pain  up  the  back  and  loin,  in  the 
testicle,  and  down  the  thigh  leaves  little  doubt  as  to  its  origin.  Hemor- 
rhage from  the  prostate  comes  away  in  clots,  and  is  usually  a  concom- 
itant of  chronic  disease  of  the  gland,  such  as  tuberculosis  or  carcinoma. 
The  prostate  is  generally  enlarged.  When  the  urethra  is  the  seat  of 
hemorrhage  it  is  generally  due  to  the  use  of  instruments.  The  blood 
comes  before  the  urine  and  is  clotted.  The  bladder  is  frequently  the 
seat  of  hemorrhage,  owing  to  the  presence  of  calculi  and  morbid 
growths,  especially  papillomata.  We  recognize  this  source  of  bleed- 
ing by  excluding  the  other  localities  and  by  the  history  of  the  case. 
As  a  rule,  the  blood  comes  with  severe  straining  at  the  end  of  urina- 


THE    GENITO-URINARY  SYSTEM.  ^yj 

tion.  An  ingenious  test  for  ascertaining  the  existence  of  a  wound  or 
abrasion  of  the  bladder  is  the  so-called  absorption  test  of  Ultzmann. 
A  solution  of  iodid  of  potassium  is  injected  into  the  bladder.  If  there 
is  a  breach  in  the  continuity  of  the  mucous  membrane,  the  iodid  is 
absorbed  and  can  be  detected  in  the  saliva.  The  absence  of  iodin  in 
the  saliva  would  indicate  an  uninjured  mucous  membrane.  The  follow- 
ing axioms  from  E.  Hurry  Fenwick  may  be  taken  as  in  the  main 
correct : 

1.  "  The  brighter  and  more  arterial  the  color  of  the  urine,  the  nearer 
the  source  of  the  bleeding  is  to  the  meatus  urinarius. 

2.  "  Long  dark  clots  like  earth-worms  or  quill-barrels  indicate  bleed- 
ing from  the  renal  pelvis,  for  they  are  clots  or  moulds  of  the  ureter. 

3.  "  Large  irregular-edged  scarlet  clots  are  derived  from  a  bladder 
source  if  traumatism  of  the  kidney  and  renal  tumor  are  excluded. 

4.  "  Blood  appearing  toward  or  at  the  finish  of  clear  urination 
denotes  a  vesical  or  a  prostatic  origin. 

5.  "  Blood  issuing  from  the  meatus  independently  of  micturition  is 
from  an  urethral  source." 

In  cases  of  doubt  the  microscope  may  throw  some  light  upon  the 
source  of  the  hemorrhage.  Blood-casts  indicate  the  renal  tissue  as  the 
seat  of  hemorrhage,  and  the  same  is  true  of  granular  casts.  When 
the  bladder  is  the  seat  of  a  morbid  growth  small  portions  of  the  neo- 
plasm are  likely  to  be  voided  with  the  urine,  and  may  be  subjected  to 
the  microscope. 

The  voided  blood  may  be  further  examined  by  allowing  it  to  subside 
in  a  conical  glass.  Of  this  test  Von  Jaksch  says  :  '*  When  blood-cells 
are  intimately  mixed  with  the  urine  in  such  a  way  that,  though  present 
in  large  quantity  and  deeply  tingeing  the  fluid,  they  do  not  form  a  sedi- 
ment after  many  hours'  standing,  it  may  be  inferred  that  the  hemor- 
rhage took  place  in  the  substance  of  the  kidney  or  in  the  renal  pelvas  or 
ureters.  If,  under  these  circumstances,  they  are  seen  with  the  micro- 
scope to  be  profoundly  altered,  having  lost  their  coloring  matter  and 
presenting  the  appearance  of  pale  yellow  rings,  the  further  conclusion 
results  that  the  blood  has  been  effused  from  the  kidney  itself,  and  the 
symptoms  point  to  acute  nephritis  or  to  a  fresh  exacerbation  in  the 
course  of  chronic  nephritis." 

Having  completed  the  examination  of  the  urine,  the  next  step  in  the 
investigation  of  the  seat  of  hematuria  is  a  physical  examination  of  the 
various  parts  of  the  urinary  tract  as  follows  : 

I.  The  Kidneys. — The  method  of  palpating  the  kidney  has  been 
already  described.  By  palpation  we  ascertain  the  presence  or  absence 
of  tenderness  of  the  kidney.  Tenderness  can  be  elicited  on  deep 
pressure  in  the  following  conditions :  viz.  pyelitis,  chronic  abscess, 
inflamed  cyst,  and  acute  suppurative  nephritis.  A  stabbing  pain 
elicited  by  pressure  over  the  front  of  the  kidney  is  very  suggestive  of 
renal  calculus,  but  too  great  stress  should  not  be  laid  upon  the  absence 
of  this  sign.  Enlargement  of  the  kidney  may  be  due  to  the  following 
conditions :  {a)  It  may  be  a  simple  hypertrophy  of  the  organ  to  com- 
pensate for  atrophy  of  its  fellow,  [b)  It  may  be  due  to  the  presence  of 
a  large  calculus  and  to  the  inflammatory  changes  which  such  foreign 
bodies  produce,     (e)  Tuberculosis  is  a  common  cause  of  enlargement: 


378  SCRG/C.IL   DIAG.VOSIS  AND    TREATMENT. 

this  condition  appears  after  the  age  of  twenty  and  the  patients  show  a 
history  of  tuberciihir  disease  in  other  organs.  (<■/)  Hydronephrosis  is 
suggestive  of  obstruction  by  calcuH  or  the  twisting  of  the  renal  vessels 
and  ureter,  [c)  Perinephritis  with  abscess  in  its  early  stages  produces 
adhesions  and  subsequent  contraction  which  draw  the  kidney  upward 
beneath  the  ribs.  (/")  Tumors  of  the  kidney,  which  in  the  vast 
majority  of  cases  prove  to  be  sarcomata  or  carcinomata. 

3.  The  Ureters. — Deep  pressure  along  the  course  of  the  ureters  may 
elicit  tenderness  in  the  whole  course  of  the  tubes,  and  is  suggestive  of 
ureteritis.  If  the  tenderness  is  only  found  in  spots,  calculi  are  probably 
the  cause.  The  examination  of  the  lower  portions  of  the  ureters  per 
rectum  in  males  and  per  vaginam  in  females  must  not  be  neglected. 

3.  Tlic  Bladder. — By  rectal  or  vaginal  examination  the  base  of  the 
bladder  can  be  felt  and  any  thickening  or  induration  readily  determined. 
After  the  age  of  forty-five  the  most  common  cause  of  thickening  is 
carcinoma,  and,  as  the  infiltration  begins  near  the  opening  of  one  or 
other  ureter,  the  thickening  occurs  to  the  right  or  left  of  the  middle 
line.  Care  should  be  taken  in  this  examination,  for  rough  palpation  is 
frequently  followed  by  profuse  hemorrhage.  Hardness  and  thickening 
are  also  felt  when  the  bladder  contains  a  calculus,  and  particularly  if 
the  stone  is  sacculated. 

Injuries   of  the   Bladder. 

Rupture. — The  bladder  is  liable  to  rupture  by  direct  violence 
applied  to  the  lower  portion  of  the  abdomen,  and  it  may  be  laid  down 
as  an  axiom  that  the  more  the  bladder  is  distended  the  greater  is  the 
risk  of  this  injury.  Bullets  and  other  missiles  are  causes  of  rupture 
which  attack  the  bladder  from  without.  The  viscus  may  be  ruptured 
from  within,  and  the  most  frequent  cause  is  the  laceration  of  its  wall  by 
a  fragment  of  bone  occurring  in  severe  fractures  of  the  pelvis.  Injuries 
to  the  rectum  or  vagina  not  infrequently  involve  the  bladder. 

The  bladder  has  sometimes  ruptured  by  over-distention,  as  when 
filled  preparatory  to  the  operation  of  cystotomy.  It  is  only  when  its 
walls  are  weakened  or  sacculated  from  previous  disease  that  this  is 
likely  to  occur.  In  any  severe  injury  of  the  pelvis  or  hypogastrium,  if 
the  patient  be  unconscious  or  has  not  the  power  to  micturate,  a  catheter 
should  be  passed  into  the  bladder  and  the  effect  carefully  noted. 

Rupture  of  the  bladder  is  of  two  kinds — intra-peritoneal  and  extra- 
peritoneal. When  the  organ  is  ruptured  and  its  contents  escape  into 
the  peritoneal  cavity,  the  most  serious  consequences  follow :  the  shock 
is  profound,  and  unless  prompt  treatment  is  resorted  to  the  patient  dies 
in  from  three  to  seven  days.  In  such  a  case  the  catheter  will  be  found 
to  draw  off  only  a  small  quantity  of  blood-stained  urine.  If  the  instru- 
ment happens  to  enter  the  laceration,  it  will  pass  freely  up  beyond  the 
natural  limit  of  the  bladder.  The  catheter,  however,  may  impinge 
against  an  unbroken  portion  of  the  bladder,  in  which  event  the  con- 
traction of  the  viscus  prevents  the  instrument  from  passing  its  normal 
distance,  and  it  appears  to  have  gone  in  a  wrong  direction.  To  settle 
the  point  pass  a  finger  into  the  rectum,  when  it  will  be  found  that  the 
catheter  is  in  the  proper  position,  but  firmly  grasped  by  the  bladder. 


THE    GENITO - URINA RY  SYS TEM.  379 

Should  the  surgeon  still  be  in  doubt  as  to  the  existence  of  intra- 
peritoneal rupture,  he  may  next  proceed  to  measure  the  capacity  of  the 
bladder.  A  rubber  catheter  is  inserted,  and  Peterson's  rubber  bag 
passed  into  the  rectum  and  distended  with  warm  water.  The  bladder  is 
then  slowly  filled  by  allowing  a  measured  quantity  of  some  mild  anti- 
septic solution  to  flow  through  the  catheter.  If  free  from  rupture,  it 
can  be  felt  to  rise  out  of  the  pelvis  and  its  limits  can  be  defined  by  per- 
cussion. After  the  injection  of  six  or  eight  ounces  the  fluid  is  allowed 
to  flow  out  by  the  catheter,  after  which  it  is  carefully  measured  and 
compared  with  the  quantity  injected.  If  the  amount  withdrawn  is 
equal  to  the  amount  injected,  the  bladder  is  not  ruptured.  Another 
means  of  diagnosis  is  the  injection  into  the  bladder  of  filtered  air 
through  a  Davidson's  syringe  over  the  outer  end  of  which  cotton  has 
been  tied.  If  there  be  an  intra-peritoneal  rupture,  the  air  will  inflate 
the  whole  abdomen  ;  if  the  bladder  be  intact,  it  alone  will  be  distended. 
Should  this  injection  produce  emphysema  of  the  cellular  tissue,  it 
proves  that  an  extra-peritoneal  rupture  of  the  bladder  has  taken  place. 

Treatment. — Several  cases  are  on  record  in  which  careful  drainasfe 
by  a  catheter,  retained  just  inside  the  neck  of  the  bladder,  has  been 
followed  by  recovery.  This  method,  however,  is  not  to  be  relied  upon. 
As  soon  as  possible  after  a  satisfactory  diagnosis  has  been  made  the 
abdominal  cavity  should  be  opened  by  an  incision  in  the  middle  line 
just  above  the  pubes.  The  rent  in  the  bladder  having  been  found,  it  is 
closed  by  a  double  row  of  carbolized  silk  sutures.  There  has  been 
considerable  discussion  ov^er  the  question  of  retaining  a  catheter  in  the 
bladder  after  this  operation.  The  weight  of  opinion  seems  to  be  in 
favor  of  dispensing  with  the  catheter.  If  the  rent  in  the  bladder  be 
closely  secured  so  as  to  prevent  leakage,  a  moderate  degree  of  disten- 
tion is  less  likely  to  do  harm  than  the  retention  of  the  catheter  in  the 
bladder  for  several  days. 

In  extra-peritoneal  rupture  of  the  bladder  the  urine  is  extravasated 
in  the  prevesical  connective  tissue  or  into  the  vesico-rectal  or  vesico- 
uterine space.  Its  diagnosis  is  arrived  at  by  exclusion  of  the  intra- 
peritoneal variety,  by  the  production  of  cellular  emphysema  when  the 
bladder  is  distended  with  filtered  air,  and  by  the  presence  of  urinary 
infiltration.  When  there  is  an  injury  which  from  its  position  evidently 
implicates  the  parts  concerned  in  micturition,  and  when,  after  examina- 
tion of  the  rectum  or  vagina,  and  the  use  of  the  catheter  as  already 
described,  there  is  still  doubt,  a  perineal  incision  should  be  made  into 
the  membranous  portion  of  the  urethra  for  the  purpose  of  digital  ex- 
ploration of  the  neck  of  the  bladder.  On  this  point  Reginald  Harrison 
observes  :  "  Many  patients  in  cases  of  this  kind  have  undoubtedly  been 
lost  for  the  want  of  that  knowledge  which  can  only  be  thus  obtained. 
Where  the  suspicion  is  grave  the  possibility  of  not  finding  such  a  lesion 
by  exploring  should  not  be  allowed  to  weigh  against  making  the  at- 
tempt. If  a  pelvic  fracture  with  rupture  of  the  viscus  or  rupture  alone 
is  discovered,  a  drainage-tube  should  be  inserted  into  the  bladder.  If 
the  prevesical  space  is  also  opened,  an  additional  aperture  above  the 
pubes  will  be  required  in  order  that  thorough  drainage  may  be  pro- 
vided. Procedures  of  this  kind  are  safe  and  slight  compared  with  the 
risk  connected  with  extravasation  of  urine  imperceptibly  going  on  in 


380  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

a  part  where  otherwise  drainage  is  impossible  and  subsequent  absorp- 
tion  uncertain." 

The  danger  of  this  form  of  rupture  is  in  the  pent-up  extravasated 
urine,  which  if  allowed  to  remain  in  the  tissues  speedily  produces  cellu- 
litis and  sloughing,  ending  in  many  cases  in  septicemia.  The  treatment, 
therefore,  must  consist  in  free  incision  to  allow  the  extravasated  urine 
to  escape,  and,  w^hen  necessary,  in  free  drainage  by  the  perineal  or 
suprapubic  route,  or  both. 

Incised  wounds  in  the  hyj^ogastric  region  are  liable  to  be  compli- 
cated with  wound  of  the  bladder ;  the  methods  of  diagnosis  are  the 
same  as  for  rupture.  When  a  wound  of  the  bladder  is  suspected,  the 
urine  should  be  drained  off  through  the  external  wound  or  by  a  cath- 
eter in  the  urethra.  Wounds  of  the  anterior  bladder-wall  heal  readily 
by  granulation,  and  in  view  of  the  slight  trouble  which  such  wounds 
give  when  intentionally  made  in  the  operation  of  cystotomy,  they 
should  be  dealt  with  on  the  principles  which  govern  that  operation. 

Retention  of  Urine. — In  its  expulsion  from  the  bladder  the  urine 
has  to  pass  through  a  long  tube  having  a  small  caliber  and  tortuous 
course — the  urethra.  Retention  or  inability  to  expel  the  urine  is  due 
to  two  classes  of  causes — viz.  those  which  produce  obstruction  in  the 
urethra,  and  those  which  result  in  a  want  of  expulsive  power.  Of 
obstructive  causes,  by  far  the  most  common  is  stricture  of  the  urethra, 
which  may  be  organic  or  spasmodic.  Other  causes  are  enlarged  pros- 
tate, inflammation  or  abscess  of  the  prostate,  impacted  calculus,  tumors 
of  the  bladder  or  urethra,  pressure  of  the  gravid  uterus,  and  atresia  of 
the  urethra  or  meatus  urinarius.  The  expulsive  power  may  be  wanting 
from  any  of  the  following  causes :  paralysis,  atony  of  the  bladder, 
reflex  influences  such  as  occur  after  the  ligature  of  hemorrhoids. 
Retention  is  common  in  shock  and  in  the  great  muscular  exhaustion 
which  attends  fevers.  Certain  drugs,  as  opium,  belladonna,  cantharides, 
and  alcohol,  by  their  toxic  influence  produce  want  of  expulsive  power. 

Diagnosis. — The  symptoms  of  retention  are  very  plain.  Besides  the 
inability  to  micturate,  the  patient  complains  of  pain  in  the  region  of  the 
bladder  and  the  kidneys.  There  is  a  constant  desire  to  empty  the 
bladder,  and  the  patient  makes  violent  straining  efforts,  which  some- 
times expel  the  contents  of  the  lower  bowel.  In  many  cases  a  few 
drops  come  aw^ay  and  lead  to  the  erroneous  belief  that  the  bladder  is 
being  emptied.  After  a  time  the  symptoms  of  uremic  poisoning  super- 
vene— viz.  rigors,  fever,  failing  circulation,  and  death.  In  less  acute 
cases  the  backward  pressure  of  the  urine  produces  destructive  changes 
in  the  kidneys.  On  palpation  the  round  distended  bladder  can  be  felt 
in  the  hypogastrium,  sometimes  extending  to  or  even  beyond  the 
umbilicus.  On  percussion  this  tumor  is  dull,  while  the  flanks  on 
either  side  are  resonant.  In  thin  persons  the  tumor  can  be  distinctly 
seen  through  the  parietes,  and  is  more  prominent  when  the  patient  is  in 
the  erect  position. 

Treatment. — This  must  depend  upon  the  cause  of  the  retention.  In 
the  majority  of  cases  the  catheter  is  indicated,  and  should  be  resorted 
to  wathout  delay.  In  some  cases  it  is  impossible  to  pass  a  catheter,  and 
aspiration  of  the  bladder  then  becoms  imperative.  This  can  be  done 
by  three  different  routes  : 


THE    GENITO-URINARY  SYSTEM.  38 1 

1.  Suprapubic. — The  operation  is  very  simple  and  free  from  danger. 
The  pubis  having  been  shaved  and  thoroughly  disinfected,  the  aspi- 
rating needle  is  inserted  in  the  middle  line  just  above  the  symphysis 
pubis,  and  the  bladder  emptied.  The  puncture  is  then  sealed  with 
iodoformized  collodion.  This  route  should  be  chosen  in  preference  to 
either  of  the  two  following. 

2.  Rectal. — Tapping  the  bladder  by  way  of  the  rectum  was  formerly 
much  in  vogue.  A  large  curved  trocar  was  passed  into  the  rectum  and 
made  to  pierce  the  bladder  just  behind  the  base  of  the  prostate. 

3.  Perineal. — This  route  is  recommended  when  there  is  enlargement 
of  the  prostate,  but  in  every  other  condition  it  is  inferior  to  the  supra- 
pubic route. 

Atony  of  the  Bladder. — Atony  of  the  bladder  is  a  condition 
which  is  almost  analogous  to  dilatation  of  the  stomach.  Its  most 
important  feature  is  that  the  viscus  cannot  e.xpel  the  whole  of  its  con- 
tents. At  the  end  of  micturition  there  is  still  a  quantity  of  urine  left 
in  the  bladder,  to  which  the  name  "  residual  urine  "  is  applied.  The 
causes  of  atony  are  numerous.  Every  male  who  has  passed  the  period 
of  middle  life  has  less  expulsive  power  than  he  had  in  youth,  and  this 
debility  increases  as  age  advances.  This,  however,  cannot  be  regarded 
as  a  morbid  condition.  The  term  "  atony  "  is  more  correctly  applied 
to  a  paresis  of  the  muscular  coats  of  the  bladder.  Coincident  with  this 
are  certain  changes  in  the  vesical  walls.  They  may  undergo  fatty 
degeneration  and  become  atrophied,  thinned,  and  distended.  An 
almost  opposite  condition  is  sometimes  observed,  wherein  the  walls 
are  changed  by  the  formation  of  fibroid  tissue,  leading  to  contraction 
of  the  viscus  and  reduction  of  its  capacity.  Among  the  causes  of 
atony  may  be  mentioned  stricture  of  the  urethra,  enlargement  of  the 
prostate,  tumors  in  the  vicinity  of  the  neck  of  the  bladder,  and  neglect 
to  empty  the  bladder  at  proper  intervals.  All  of  these  causes  act  in 
one  direction — they  produce  ov^er-distention.  A  single  failure  to  relieve 
the  bladder  at  the  proper  time  is  sufficient  to  produce  atony. 

Symptoms. — Atony  of  the  bladder  is  to  be  taken  into  consideration 
when  there  is  any  cause  of  over-distention,  as  stricture,  enlarged  pros- 
tate, etc.  After  the  patient  has  micturated  and  emptied  the  bladder  to 
the  extent  of  his  ability,  a  catheter  should  immediately  be  passed.  If  it 
be  found  that  an  ounce,  two  ounces,  even  a  larger  quantity,  of  residual 
urine  flows  through  the  catheter,  the  case  is  one  of  either  atony  or 
sacculation  of  the  bladder.  It  may  be  impossible  to  make  a  differential 
diagnosis  between  the  two.  In  sacculation  a  soft  catheter  may  empty 
the  general  cavity  of  the  bladder,  and  after  all  the  urine  has  ceased  to 
flow  a  change  in  the  position  of  the  instrument  may  be  followed  by  the 
flow  of  a  quantity  of  residual  urine.  In  atony  the  residual  urine  comes 
away  with  any  form  of  catheter. 

Treatment. — The  most  serious  feature  of  atony  is  the  retention  of 
the  residual  urine  and  the  chain  of  evils  which  are  apt  to  follow — viz. 
decomposition  of  urine,  cystitis,  retention,  and  degenerative  changes  in 
the  kidney.  To  guard  against  these  the  regular  and  persistent  use  of 
the  catheter  is  necessary,  and  the  patient  should  be  taught  to  use  the 
instrument  for  himself  The  frequency  of  its  employment  must  depend 
upon  the  amount  of  residual  urine.     When  after  the  act  of  micturition 


382  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

the  bladder  still  retains  four  ounces,  the  catheter  should  be  used  night 
and  morning ;  when  six  ounces  are  retained,  the  instrument  is  indicated 
three  times  a  day ;  and  if  there  be  eight  ounce  of  residual  urine,  it  will 
need  to  be  withdrawn  every  six  hours.  Use  the  catheter  once  a  day  for 
cverv  tzc'o  ounces  of  residual  urine.  The  patient  should  be  taught  not 
only  the  use  of  the  catheter,  but  the  manner  of  disinfecting  it  and 
keeping  it  surgically  clean. 

The  medicines  of  any  value  in  giving  more  healthy  tone  to  the  walls 
of  the  bladder  are  strychnin,  iron,  tincture  of  cantharides,  and  ergot, 
but   too  much  must  not  be  expected  from  their  employment. 

Electricity  is  of  great  value  in  mild  recent  cases,  and  is  a  help  to 
other  measures  when  the  condition  is  long  continued  and  severe.  It  is 
employed  as  follows  :  an  insulated  electrode  is  passed  into  the  bladder, 
while  the  other  electrode  is  applied  to  the  hypogastric  region  or  passed 
into  the  rectum.  A  mild  current  is  employed,  and  gradually  increased 
till  the  patient  complains  of  discomfort. 

When  cystitis  complicates  atony,  special  treatment  must  be  directed 
to  the  inflammator)'  condition. 

Sacculation  and  Pouching  of  the  Bladder. — Two  other  con- 
ditions closely  allied  to  atony  are  sacculation  and  pouching  of  the 
bladder.  These  terms  are  frequently  used  as  synonymous.  Sacculation 
may  be  defined  as  a  hernia  of  the  vesical  mucous  membrane  through  a 
weakened  part  of  the  muscular  coat  of  the  bladder ;  hence  this  portion 
of  the  bladder  has  no  power  to  empty  itself  and  becomes  a  receptacle 
for  residual  urine  and  for  calculi.  It  is  usually  the  result  of  over- 
distention,  and  may  occur  at  any  age  and  at  any  portion  of  the  organ. 
Of  the  causes  which  lead  to  sacculation  obstruction  to  the  flow  of  urine 
plays  the  most  important  part.  Intra-uterine  pressure  is  also  a  not 
infrequent  cause,  while  a  third  class  of  cases  are  of  traumatic  origin. 

The  diagnosis  of  sacculation  is  not  always  easy.  A  soft  or  flexible 
catheter  passed  into  the  bladder  is  found  to  draw  off  a  certain  quantity 
of  urine ;  the  position  of  the  instrument  is  changed  and  the  flow^ 
recommences.  This  is  ver)^  suggestive  of  sacculation,  and  if  the  cha- 
racter of  the  urine  drawn  off  from  the  two  compartments  is  found  to  be 
materially  different,  the  evidence  is  conclusive.  Guthrie  demonstrated 
the  presence  of  sacculation  by  injecting  the  bladder  with  twelve  ounces 
of  warm  water,  and  finding  that  only  ten  ounces  could  be  withdrawn. 
Sometimes  when  digital  examination  is  made  by  rectum  or  vagina 
the  sacculation  can  be  felt  as  a  tumor  in  the  proximity  to  bladder. 
Should  the  examiner  meet  with  a  tumor  of  this  character,  an  effort 
should  be  made  to  pass  a  catheter  into  it ;  if  he  succeed,  the  tumor 
will  quickly  disappear. 

One  of  the  most  serious  results  of  sacculation  is  that  it  affords  a 
hiding-place  for  calculi.  Stones  thus  imbedded  cannot  be  dealt  with  by 
the  lithotrite,  and  even  if  they  could  the  detritus  would  be  sure  to 
collect  in  the  pouch  and  renew  the  trouble.  The  best  way  to  deal 
with  a  stone  thus  sacculated  is  to  make  a  suprapubic  cystotomy,  remove 
the  stone,  and  treat  the  sacculation  by  drainage  (Reginald  Harrison). 

Pouching  differs  from  sacculation  in  that  the  whole  thickness  of  the 
bladder  is  involved.  It  is  also  confined  to  the  most  dependent  part  of 
the  bladder,  and  is  in  nearly  all  cases  met  with  in  persons  well  advanced 


THE    GENITO-URINARY  SYSTEM.  383 

in  years.  A  good-sized  stone  has  a  tendency  to  cause  the  floor  of  the 
bladder  to  form  a  pouch,  and  when  this  occurs  the  removal  of  the 
calculus  can  only  be  accomplished  by  a  cutting  operation. 

Treatment. — Drainage  of  the  bladder  is  the  best  method  of  dealing 
with  sacculation  or  pouching.  The  effect  of  a  sea-voyage  is  often 
remarkable ;  on  this  point  Mr.  Harrison  observes :  "I  have  known 
thick,  cystitic  urine,  due  to  the  pollution  of  the  general  cavity  of  the 
bladder  by  the  contents  of  a  stagnant  sac,  entirely  recover  itself  when 
placed  under  these  conditions.  The  constant  movement  of  the  ship 
both  by  day  and  night  and  in  whatever  position  the  body  may  occupy 
renders  stasis  of  any  of  the  fluids  of  the  body  impossible,  and  thus  one 
element  necessary  for  decomposition  is  removed.  The  immunity  of 
seamen  from  stone  and  certain  bladder  affections  may  in  some  measure 
be  due  to  this.  In  one  instance  at  present  under  my  observation,  where 
there  is  very  little  doubt  the  patient  has  a  sacculated  bladder,  the  urine 
is  invariably  clear  and  normal  when  he  is  at  sea,  and  turbid  and  offen- 
sive when  he  is  on  shore  for  any  length  of  time.  Yet  in  other  respects, 
as  far  as  I  can  judge,  the  conditions  are  the  same." 

Cystitis,  or  Inflammation  of  the  Bladder. — It  is  customary  to 
divide  cystitis  into  two  varieties,  acute  and  chronic.  The  symptoms  are 
almost  identical  in  both,  and,  as  every  degree  of  chronicity  is  met  with, 
it  is  sometimes  difficult  to  draw  a  dividing-line. 

Acute  cystitis  may  arise  from  a  great  variety  of  causes — for  exam- 
ple, direct  injury  to  the  bladder-walls  by  the  unskilful  use  of  sounds  or 
other  instruments  ;  the  presence  of  foreign  bodies,  either  pushed  into 
the  bladder  by  way  of  the  urethra  or  arising  from  within  in  the  shape 
of  calculi  or  fragments  thereof;  the  use  of  cantharides ;  the  extension 
of  inflammation  from  the  urethra,  as  in  stricture  or  simple  urethritis ; 
the  infection  of  micro-organisms,  as  the  gonococcus  or  tubercle  bacillus, 
and  the  presence  of  new  growths,  as  carcinoma. 

One  of  the  chief  dangers  of  cystitis  is  the  liability  of  the  inflamma- 
tion to  spread  by  way  of  the  ureters  to  the  kidney,  causing  a  pyelitis,  a 
pyelo-nephritis,  disorganization  of  the  kidney,  and  frequently  death. 
The  changes  which  take  place  in  the  bladder-walls  are  congestion, 
thickening  of  the  mucous  membrane,  desquamation  of  the  epithelial 
lining,  and  the  formation  of  raw  surfaces.  In  advanced  stages  of  the 
disease  the  tissues  become  infiltrated  with  pus,  and  ulceration  and 
sloughing  are  not  uncommon.  In  some  instances  the  inflammation  is 
attended  with  the  formation  of  a  false  membrane,  which  may  be  voided 
in  pieces  or  in  casts  of  considerable  portions  of  the  bladder.  This  may 
be  a  true  diphtheritic  membrane,  the  disease  attacking  the  bladder 
simultaneously  with  other  regions  of  the  body. 

Symptoms. — The  first  symptom  to  usher  in  an  attack  of  acute 
cystitis  is  generally  frequent  viicturition.  This  increases ;  the  patient 
is  obliged  to  empty  his  bladder  more  and  more  frequently,  till  at  last 
he  is  kept  constantly  getting  in  and  out  of  bed.  Vesical  tenesmus  is 
also  a  prominent  feature ;  the  sufferer  strains,  trembles,  and  perspires, 
but  can  only  expel  a  few  drops  of  urine  at  a  time.  A  feeling  of  weight 
in  the  perineum  is  not  uncommon,  attended  with  a  sensation  as  if  some 
foreign  body  were  there  which  ought  to  be  expelled. 

A  few  hours  after  the  onset  of  the  symptoms  just  mentioned  pain 


384  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

becomes  a  prominent  feature.  It  is  usually  deep-seated,  and  felt  above 
the  pubes,  down  the  ^roin  and  thighs,  and  at  the  end  of  the  urethra. 
Pressure  over  the  bladder  elicits  tenderness. 

CJiangcs  in  the  urine  can  be  observed  at  an  early  period  of  the  dis- 
ease. It  is  high  colored,  and  at  the  end  of  each  effort  to  empty  the 
bladder  a  few  drops  of  blood  are  expelled.  More  or  less  mucus 
gives  the  urine  a  thickened  appearance ;  lithatcs  appear  in  abundance, 
and  later  the  fluid  becomes  ammoniacal. 

The  coiistitutio)ial  symptoms  do  not  follow  a  definite  course.  Rigors 
or  chills  are  sometimes  met  with,  and  a  high  temperature  and  rapid 
pulse  may  exist  throughout  the  attack. 

Treatment. — Whatever  the  form  in  which  cystitis  presents  itself,  the 
first  indication  is  to  ascertain  and  remove  the  cause.  Fragments  of 
stone,  retained  unhealthy  urine,  gonorrheal  secretions,  or  any  other 
excitants  should  be  sought  for  and  either  removed  or  their  influence 
counteracted.  The  pain  will  call  most  loudly  for  prompt  action.  Injec- 
tions of  warm  water  into  the  rectum  often  afford  great  relief,  but,  as  a 
rule,  opiates  will  be  required.  Half  a  grain  of  morphin  dissolved  in 
half  a  pint  of  water  and  at  a  temperature  of  about  110°  F.,  injected 
into  the  rectum,  will  be  followed  by  an  exquisite  sense  of  relief,  putting 
a  speedy  stop  to  pain,  tenesmus,  and  constant  micturition.  Supposi- 
tories will  produce  the  same  effect,  but  their  action  is  not  so  prompt. 
The  patient  should  keep  his  bed,  be  restricted  to  a  light  diet,  and  par- 
take freely  of  diluent  drinks.  Hot  fomentations  and  hip-baths  are 
favorite  remedies,  and  the  internal  administration  of  hyoscyamus  has 
long  enjoyed  the  reputation  of  being  the  most  useful  single  remedy  in 
inflammatory  affections  of  the  bladder. 

Chronic  cystitis  is  frequently  a  continuation  of  the  acute  form.  It 
is  often  a  result  of  enlarged  prostate,  of  calculus,  atony,  stricture,  and 
new  growths.  Its  origin  is  often  traceable  to  the  kidney,  to  defective 
digestion,  or  to  gout.  The  symptoms  in  general  are  those  of  the  acute 
form,  but  not  so  pronounced.  There  may  be  little  pain ;  tenesmus  may 
be  slight  or  absent.  Micturition  is  usually  less  frequent,  and  the 
majority  of  patients  are  able  to  move  about,  but  they  suffer  incon- 
venience which  makes  their  lives  more  or  less  of  a  burden.  The  urine 
seldom  contains  blood,  but  to  offset  this  it  is  thick,  filled  with  ropy 
mucus  or  pus,  and  often  ammoniacal  and  foul-smelling.  Catarrh  of  the 
bladder  is  a  popular  name  for  this  disease. 

Treatment. — Removal  of  the  cause  must  claim  the  closest  attention. 
Many  a  patient  who  has  suffered  from  chronic  cystitis  for  years  has 
been  restored  to  health  after  he  had  fallen  into  the  hands  of  a  surgeon 
who  took  the  pains  to  search  for,  find,  and  remove  a  calculus  which  had 
never  been  suspected  by  previous  advisers.  TJie  treatment  of  ehrojiic 
cystitis  should  never  be  begun  until  a  most  thorough  ond  searching  ex- 
amination has  been  made  for  the  cause.  The  prostate  is  responsible  for 
a  large  proportion  of  all  cases.  A  digital  examination  by  the  rectum 
will  speedily  settle  the  question  as  to  whether  the  gland  is  enlarged.  A 
vesical  calculus  will  manifest  its  presence  by  the  symptoms  peculiar  to 
stone,  and  the  bladder  should  be  searched  for  stone. 

Urethral  stricture  is  another  cause  which  should  receive  careful 
attention.     It  is  readily  recognized  by  the  diminished  or  forked  stream 


THE    GENITO-URINARY  SYSTEM. 


385 


of  urine,  difficulty  in  micturition,  and  by  examination  with  the  urethral 
sound  or  catheter. 

The  general  treatment  may  be  summed  up  under  the  following 
heads : 

1.  Remedies  administered  internally  or  by  the  rectum.  The  drugs 
which  have  found  most  favor  in  the  treatment  of  chronic  cystitis  are 
buchu,  pareira  brava,  oil  of  sandalwood,  balsam  of  copaiba  and  cubebs, 
uva  ursi,  etc.  Quinin,  salol,  and  boric  acid  are  valuable  on  account 
of  their  power  to  disinfect  the  urine  and  prevent  the  growth  of  micro- 
organisms. 

2.  Irrigation.  Washing-  the  bladder  with  warm  sterilized  water  or 
boric-acid  solution  is  very  important,  after  which  the  organ  is  ready  to 
receive  an  injection  of  one  or  other  of  the  solutions  mentioned  in  the 
following  paragraph. 

3.  Injections.  Of  all  the  remedies  used  for  injecting  the  bladder, 
nitrate  of  silver  must  take  the  first   place.     Nothing  will  act   more 


Fig.  163. —  Keyes'  irrigator  for  bladder. 

promptly  in  destroying  the  bacteria,  and  its  action  upon  a  chronically 
inflamed  mucous  membrane  is  superior  to  anything  else.  The  bladder 
is  first  washed  out  with  sterilized  water.  Two  ounces  of  water  holding 
five  grains  of  nitrate  of  silver  are  then  allowed  to  flow  into  the  bladder 
and  out  again,  after  which  the  bladder  is  again  washed  out  with  steril- 
ized water.  Other  solutions  which  are  recommended  for  irrigation  are 
the  following :  boric  acid  of  a  strength  of  5  to  10  per  cent. ;  bichlorid 
of  mercury,  i  :  10,000;  permanganate  of  potash,  3  per  cent.  ;  carbolic 
acid,  I  :  500.  The  method  of  irrigating  the  bladder  is  shown  in  Fig.  163. 
It  consists  of  a  rubber  bottle  {A)  which  holds  about  a  pint  and  can  be 
suspended  at  a  height  of  three  or  four  feet  above  the  level  of  the 
patient's  bladder ;  a  rubber  tube  (i>)  five  feet  in  length,  ending  in  a 
25 


386  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

Stop-cock  ({T),  which  directs  the  fluid  into  the  catheter  {D)  or  the 
outlct-jMpc  (A).  The  apparatus  is  used  as  follows :  Fill  the  reservoir 
and  hang  it  up ;  open  the  stop-cock  to  allow  the  fluid  to  expel  the  air 
from  the  tubing;  then  pass  the  catheter.  Turn  the  stop-cock  (6^)  to 
allow  the  fluid  to  enter  the  bladder,  and  when  the  viscus  is  full  reverse 
the  tap  and  allow  the  fluid  to  escape  from  bladder  and  run  into  the 
receptacle  (4).  By  alternating  this  action  the  bladder  is  repeatedly 
filled  and  emptied. 

A  simpler  contrivance  is  a  glass  funnel  connected  with  a  catheter  by 
means  of  a  rubber  tube  two  feet  in  length.  The  funnel  is  elevated  and 
the  fluid  poured  into  it,  which  by  gravitation  reaches  the  bladder.  By 
lowering  the  funnel  below  the  level  of  the  patient's  pelvis  the  fluid 
escapes.  The  objection  to  this  method  is  that  it  allows  air  to  enter  the 
bladder. 

Drainage. — In  spite  of  the  most  persevering  efforts  in  the  use  of 
these  remedies  some  cases  will  show  no  improvement.  Another 
resource  is  still  open  to  the  patient,  which  gives  not  only  a  fair  prospect 
of  relief  from  pain  and  constant  urination  and  tenesmus,  but  a  possi- 
bility of  perfect  cure.  This  is  perineal  cystotomy.  By  means  of  it  the 
bladder  can  be  thoroughly  drained,  and  the  irrigations  and  injections 
given  a  better  opportunity  to  exert  their  full  benefit  upon  the  inflamed 
surface. 

Stone  in  the  Bladder. — In  its  normal  condition  urine  contains 
about  90  per  cent,  of  water  in  which  are  dissolved  10  per  cent,  of 
organic  and  inorganic  materials.  The  organic  substances  are  urea  and 
uric  acid.  Of  these,  uric  acid  plays  an  important  part  in  the  formation 
of  calculi,  for,  although  it  exists  in  the  proportion  of  only  i  to  looo 
in  the  urine,  it  enters  into  the  formation  of  a  great  majority  of 
vesical  calculi.  The  inorganic  constituents  are  sodium,  potassium,  and 
magnesium,  bases  with  which  uric  acid  unites.  These  bases  also  unite 
-with  sulphuric  and  phosphoric  acids  to  form  corresponding  salts.  Nor- 
mal urine  also  contains  chlorids,  mucus,  and  epithelium. 

While  these  substances  are  held  in  solution  all  is  well.  When  they 
form  deposits  and  their  particles  aggregate  around  a  nucleus,  stone  is 
the  result.  In  the  majority  of  cases  uric-acid  crystals  form  the  nucleus, 
the  crystals  being  held  together  by  the  renal  or  vesical  mucus.  A  drop 
of  dried  blood  or  a  foreign  body  in  the  bladder,  as  a  piece  of  catheter  or 
a  fragment  of  bone,  is  sometimes  the  nucleus.  Nuclei  composed  of 
uric  acid  or  of  oxalate  of  lime  are  found  in  the  kidney,  and  increase  in 
size  as  they  lie  in  the  renal  pelvis  or  the  bladder.  When  composed  of 
the  triple  phosphates  the  calculi  begin  to  form  in  the  bladder  and  owe 
their  origin  to  ammoniacal  urine. 

The  examination  of  a  patient  for  urinar}^  calculus  may  be  considered 
under  the  following  heads  : 

History. — A  large  proportion  of  cases  of  bladder-stone  will  be 
found  to  have  had  their  origin  in  the  kidney.  The  passage  of  the 
stone  thence  to  the  bladder  is  marked  by  an  attack  of  renal  colic,  and 
the  patient  will  probably  give  a. graphic  description  of  a  terrible  attack 
of  pain  which  occurred  weeks  or  months  previously,  and  which  was 
followed  by  freedom  from  suffering  until  the  bladder  began  to  give 
trouble.     Chronic  cystitis  should  excite  suspicion  of  stone,  for  it  may 


THE    GENITO-URINARY  SYSTEM.  387 

either  be  the  result  or  the  cause  of  a  calculus.  The  irritation  set  up 
by  a  stone  invariably  produces  cystitis.  The  existence  of  cystitis,  on 
the  other  hand,  is  attended  with  copious  secretion  of  mucus  or  muco- 
pus,  affording  the  colloid  material  which  binds  together  the  particles 
that  form  the  nucleus  of  a  stone.  Enlargement  of  the  prostate  is 
another  powerful  predisposing  cause,  owing  to  the  changes  which  take 
place  in  the  urine  and  in  the  bladder  as  a  result  of  obstruction  to  the 
flow  of  urine  and  the  consequences  of  that  obstruction — viz.  atony  and 
retention.  For  similar  reasons  inflammation  or  catarrh  of  any  part  of 
the  urinary  tract  is  a  predisposing  cause  of  stone.  Persons  who  have 
been  sufferers  from  gout  or  rheumatism  are  liable  to  stone,  and  a  history 
of  one  or  other  of  these  diseases  should  arouse  our  suspicion. 

As  regards  age,  childhood  and  advanced  life  afford  the  largest  num- 
ber of  cases.  Children  suffer  from  uric-acid,  old  men  from  phosphatic, 
calculi.  Females  on  account  of  the  shortness  of  the  urethra  and  the 
freedom  from  causes  of  obstruction  rarely  suffer  from  stone  in  the 
bladder. 

Symptoms  Indicating  the  Presence  of  Stone. — Frequent  micturi- 
tion is  generally  the  first  symptom  to  draw  the  patient's  attention  to  the 
fact  that  something  is  going  wrong.  At  first  he  may  be  called  to  urinate 
once  in  three  or  four  hours,  the  frequency  gradually  increasing  until  he 
is  compelled  to  empty  his  bladder  every  few  minutes.  This  symptom  is 
more  marked  in  children  than  in  those  advanced  in  years.  It  is  in- 
creased by  exercise,  by  walking  or  running,  by  riding  on  horseback  or 
in  a  jolting  vehicle.  As  might  be  expected,  the  patient  is  much  better 
during  the  hours  which  he  spends  in  bed.  A  small  stone  moves  freely 
in  the  bladder  with  every  change  in  the  position  of  the  patient's  body, 
while  a  large  stone  may  form  for  itself  a  bed  in  the  floor  of  the  bladder 
and  be  subject  to  very  little  movement.  This  explains  the  clinical  fact 
that  not  only  frequent  micturition,  but  pain,  is  often  more  marked  when 
the  calculi  are  small. 

Sudden  arrest  of  the  floiv  of  2irine  is  a  symptom  of  great  value.  It 
is  most  marked  when  the  stone  is  small,  and  during  micturition  rolls 
into  the  mouth  of  the  urethra  or  the  neck  of  the  bladder,  forming  a 
ball  valve  and  obstructing  the  flow.  Many  patients  by  painful  expe- 
rience learn  to  alleviate  this  by  assuming  an  attitude  which  keeps  the 
stone  well  away  from  the  urethral  opening. 

Pain. — It  is  possible  for  a  good-sized  stone  to  exist  without  causing 
much  pain,  but  this  is  very  exceptional.  If  the  stone  is  firmly  imbedded 
in  a  vesical  pouch  or  coated  with  a  colloid  material  which  covers  up  its 
rough  points  and  gives  it  a  smooth,  soft  surface,  it  may  produce  little 
irritation.  As  an  almost  invariable  rule  stone  in  the  bladder  is  attended 
with  intense  suffering.  The  pain  has  two  characteristics :  {a)  It  is  felt 
at  the  under  surface  of  the  penis  near  the  meatus.  This  is  why  little 
boys  with  stone  in  the  bladder  keep  up  a  constant  pulling  of  the  pre- 
puce till  it  becomes  greatly  elongated  and  inflamed,  {li)  The  period  of 
greatest  intensity  is  at  the  end  of  micturition.  The  bladder  contracts 
upon  the  stone,  and  woe  betide  the  poor  sufferer  if  the  surface  of  the 
calculus  is  rough,  hard,  and  nodular,  as  is  generally  the  case  when  it 
is  composed  of  oxalate  of  lime !  Firmly  closing  upon  the  stone,  the 
bladder  may  hold  its  grip  until  the  slowly  collecting  urine  comes  be- 


388  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

tween  it  and  the  stone  and  affords  a  brief  respite.  Distal  pains  of  reflex 
character  are  not  uncommon.  The  rectum  and  perineum  are  most 
liable  to  suffer,  but  parts  more  remote  are  sometimes  affected,  as  the 
lungs,  the  stomach,  the  extremities,  the  back,  and  the  thighs. 

Hematuria  is  a  symptom  frequently  observed,  and  is  a  natural  con- 
sequence of  the  rough  treatment  to  which  the  mucous  membrane  is 
subjected  by  the  presence  of  a  stone.  It  is  most  marked  when  the 
patient  takes  exercise  or  is  subjected  to  jolting,  as  in  travelling.  The 
character  of  the  urine  is  worthy  of  attention.  It  is  generally  loaded 
with  muco-pus,  but,  as  this  simply  indicates  cystitis,  it  is  not  of  much 
value  from  a  diagnostic  standpoint.  The  passage  of  small  calculi,  the 
so-called  "  gravel,"  is  much  more  significant. 

The  symptoms  just  mentioned  are  not  sufficient  to  base  a  diagnosis 
upon.  Their  presence  in  whole  or  in  part  simply  warrants  us  to  proceed 
to  the  third  part  of  the  investigation — viz. : 

Sounding  the  Bladder. — We  cannot  introduce  the  finger  into  the 
bladder,  so  we  use  a  long,  slender  metallic  finger  called  a  sound.  This 
instrument  should  have  a  straight  shaft,  a  flat  handle,  and  a  short  curve. 
It  should  be  of  the  size  of  a  No.  8  English  or  13  French  bougie.  Two 
sizes  are  convenient — one  having  a  slight  curve  (Fig.  164),  the  other 


Fig.  164. — Harrison's  searcher. 

having  a  short,  abrupt  curve  for  the  purpose  of  searching  the  part  just 
behind  the  prostate,  and  which  is  likely  to  be  the  hiding-place  of  a 
stone. 

The  indications  for  resorting  to  the  use  of  bladder-sounds  are  thus 
laid  down  by  Reginald  Harrison  : 

1.  "In  children  suffering  from  vesical  irritability,  incontinence  of 
urine,  sudden  interruption  to  micturition,  retention  of  urine,  blood  in 
the  urine,  penile  irritation  inducing  the  pulling  of  the  foreskin,  and 
prolapse  of  the  bow^el. 

2.  "  In  the  vesical  irritability  of  adults  after  attacks  of  renal  colic, 
where  there  are  reasons  for  believing  a  calculus  may  be  retained  in  the 
bladder;  in  cases  of  hematuria  of  a  doubtful  nature,  or  of  chronic 
muco-purulent  or  ammoniacal  urine,  or  where  the  urine  contains  on 
standing  an  excess  of  cloudy  mucus. 

3.  "  In  pain  after  micturition  referred  to  the  end  of  the  penis. 

4.  "  In  the  enlarged  prostate  of  elderly  persons,  with  persisting^ 
symptoms  of  vesical  irritability. 

5.  "  Where  calculi  or  portions  of  them  have  been  spontaneously 
passed  and  symptoms  of  irritation  continue. 

6.  "  In  cases  of  acute  vesical  spasm  terminating  the  act  of  micturi- 
tion, or  where,  though  the  bladder  contains  but  little  urine,  there  is 
frequently  a  sudden  and  uncontrollable  desire  to  micturate. 

"  Though  the  indications  of  stone  may  be  numerous,  it  will  be  seen 
that  they  all  have  reference  to  either  a  persisting  source  of  irritation 


THE    GENITO-URINARY  SYSTEM.  389 

within  the  bladder  or  a  mechanical  interference  with  the  act  of  mic- 
turition." 

The  operation  of  sounding  for  stone  is  not  to  be  lightly  undertaken, 
and,  when  employed,  the  patient  should  be  as  carefully  prepared  as  for 
a  major  cutting  operation.  If  he  has  just  completed  a  long  journey 
by  rail  or  carriage,  time  should  be  given  him  to  rest  and  to  allow  the 
bladder  to  recover  from  the  irritation  consequent  to  the  jolting  move- 
ment inseparable  from  such  a  journey.  The  history  and  present  con- 
dition of  the  patient  should  be  thoroughly  gone  into,  and  a  specimen 
of  his  urine  taken  for  chemical  and  microscopic  examination.  The 
bowels  should  be  emptied,  and  just  before  the  passage  of  the  instru- 
ment the  urethra  should  be  washed  out  with  a  mild  antiseptic  solution. 
None  but  a  slovenly  or  antiquated  practitioner  would  use  an  instrument 
without  having  first  boiled  or  otherwise  disinfected  it,  and  the  operator's 
hands  should  be  as  carefully  scrubbed  as  if  about  to  begin  a  laparotomy. 
The  patient  should  lie  on  a  table ;  his  knees  should  be  drawn  up  to  flex 
the  thighs  upon  the  abdomen,  and  the  limbs  should  be  slightly  sepa- 
rated. The  bladder  should  be  moderately  filled,  either  by  injecting  it 
with  warm  boric-acid  solution  or  by  having  the  patient  retain  his  urine 
for  several  hours  previous  to  the  examination. 

Passing  the  Soiuid. — The  instrument,  having  been  disinfected  by 
boiling,  is  dipped  in  sterilized  olive  oil,  and  while  still  warm  is  passed 
into  the  bladder  in  the  following  manner :  Stand  at  the  patient's  left 
side ;  hold  the  sound  in  the  right  hand  and  take  the  penis  between  the 
thumb  and  fore  finger  of  the  left.  Put  the  organ  gently  on  the  stretch 
in  such  a  position  that  the  dorsum  faces  the  abdominal  wall,  with  the 
urethra  free  from  kinks  or  twists.  Insert  the  end  of  the  sound  into  the 
urethra,  keeping  the  instrument  parallel  to  Poupart's  ligament.  The 
handle  is  held  low  and  the  penis  gently  stretched  while  the  instrument 
is  passed  in  to  about  the  membranous  portion  of  the  urethra.  Sweep 
the  handle  round  to  the  middle  line  of  the  body,  still  keeping  close  to 
the  abdomen  ;  then  press  the  instrument  gently  downward  toward  the 
feet  and  make  slight  traction  upon  the  penis.  The  instrument  should 
glide  a  few  inches  farther  in  this  direction ;  when  it  stops  raise  the 
handle,  keeping  it  exactly  in  the  middle  line,  and,  passing  the  perpen- 
dicular, depress  it  between  the  thighs.  During  the  time  that  the  right 
hand  is  describing  this  arc  of  a  circle  the  fingers  of  the  left  hand  are 
shifted  to  the  perineum  beneath  the  scrotum,  where  they  aid  in  direct- 
ing the  sound  through  the  membranous  and  prostatic  portions  of  the 
urethra  into  the  bladder.  Sometimes  it  will  be  found  better  to  take  the 
instrument  in  the  left  hand  just  after  it  has  passed  the  perpendicular, 
and  to  use  the  index  and  middle  fingers  of  the  right  hand,  placed  on 
each  side  of  the  root  of  the  penis,  to  make  downward  pressure. 

Searching  for  Stone. — Having  now  inserted  the  sound,  a  careful 
search  must  be  made,  not  by  pushing  the  instrument  about  on  a 
happy-go-lucky  chance  of  striking  against  a  stone,  but  in  a  systematic 
manner.  We  know  that  the  sound  is  in  the  bladder  by  the  freedom 
with  which  we  can  move  the  tip  of  the  instrument  when  we  rotate  the 
handle,  and  by  the  instrument  remaining  in  the  middle  line  and  point- 
ing away  from  the  pubis  when  the  hand  is  removed.  The  middle  line 
should   first  be  explored  by  slightly  withdrawing  and  replacing  the 


39° 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


sound,  raising  and  depressing  the  handle.  It  should  then  be  rotated 
so  as  to  make  the  tip  of  the  instrument  turn  to  one  side,  and  as  it  is 
slowly  and  gently  pushed  in  and  out  the  curve  is  made  to  feel  the  floor 
of  the  ca\ity  to  both  right  and  left  of  the  middle  line.  It  may  be  that 
in  all  these  maneuvers  no  stone  is  felt,  and  yet  the  sound  repeatedly 
passes  over  it.  This  is  because  the  calculus  is  lying  in  a  pouch  on  the 
bladder-floor  just  behind  the  prostate,  and  the  instrument  with  a  slight 
curve  fails  to  touch  it.  This  possibility  should  always  be  taken  into 
account,  and,  failing  to  find  a  stone  with  the  first  sound,  a  second  instru- 
ment with  a  short,  abrupt  curve  should  be  employed  and  the  search 
renewed.  It  is  not  advisable  to  state  positively  that  the  patient  has  no 
stone  in  the  bladder  on  the  data  obtained  from  one  examination.  A 
second  examination  a  few  days  later  will  perhaps  yield  different  results, 
as  many  surgeons  have  found  by  experience. 

The   presence   of  a   stone   is    recognized   by  the    sensation    com- 
municated to  the  hand  when  the  sound  strikes  a  hard  body,  and  by  the 


Fig.  165. — Diagnosis  of  calculus  (Fenwick). 

peculiar  chck  which  can  generally  be  distinctly  heard.  To  magnify 
this  "  click  "  a  stethoscope  can  be  placed  over  the  hypogastrium,  or  one 
end  of  a  rubber  tube  can  be  attached  to  the  bladder-sound  and  the 
other  end  applied  to  the  examiner's  ear.  As  aids  to  the  examination 
the  following  procedures  may  be  mentioned :  The  anterior  wall  of  the 
bladder  can  be  brought  within  reach  of  the  sound  by  the  surgeon 
pressing  upon  the  abdominal  wall.  A  finger  in  the  rectum  can  be 
used  with  advantage  to  raise  the  bas-fond  of  the  bladder  and  bring  it 
in  contact  with  the  sound.  In  cases  of  enlarged  prostate  a  stone  is  apt 
to  lie  hidden  behind  the  gland  and  thus  elude  the  searcher ;  raising  the 
hips  or  placing  the  patient  in  the  Trendelenburg  position  will  cause  the 
stone  to  roll  back  toward  the  fundus.  In  the  case  of  very  small  stones 
a  hollow  sound  is  useful.  By  means  of  it  a  portion  of  the  bladder- 
contents  can  be  removed  while  the  patient  is  standing  upright,  and,  if 
the  sound  be  slowly  withdrawn  and  turned  from  side  to  side  until  it 
comes  to  the  neck  of  the  bladder,  the  calculi,  however  small  they  may 


THE    GENITO- URINARY  SYSTEM. 


391 


be,  are  sure  to  come  in  contact  with  the  instrument.  Bigelow's 
evacuator  and  wash-bottle  sometimes  succeed  in  finding  and  removing 
a  small  stone  which    cannot  be  felt  with  a  sound. 

For  the  detection  of  stones  lying  in  a  deep  post-prostatic  pouch  E. 
Hurry  Fenwick  recommends  plunging  a  long  trocar  and  cannula  into 
the  suprabubic  region  and  directly  backward  to  the  stone  (Fig.  165). 

Examination  by  the  Cystoscopc. — In  doubtful  cases  the  use  of  the 
cystoscope  in  skilful  hands  is  of  great  value.  Leiter's  cystoscope  (Fig. 
166)  is  of  the  shape  and  size  of  a  No.  21  F.  sound.     At  the  extremity 


Fig.  i66. — Leiter's  cystoscope. 

it  carries  an  Edison  incandescent  lamp  enclosed  in  a  cup  having  a  small 
aperture  fitted  with  a  plate  of  rock  cystal.  Two  conductors  passing 
within  the  shaft  connect  with  the  little  sockets  for  the  lamp  and  com- 
plete the  circuit.  The  bend  of  the  instrument  contains  a  prism.  To 
make  use  of  the  cystoscope  the  patient  should  be  placed  in  the  dorsal 
or  the  lithotomy  position.  The  bladder  ought  to  contain  six  to  eight 
ounces  of  clear  urine.  Should  the  urine  be  turbid,  wash  out  the  blad- 
der and  inject  boric-acid  solution  ;  if  the  urine  is  tinged  with  blood, 
irrigate  the  bladder  with  equal  parts  of  extract  of  hamamelis  and  hot 
water.  Anesthesia  may  be  local  or  general  or  may  be  dispensed  with. 
Should  cocain  be  employed,  it  must  be  kept  in  mind  that  fatal  results 
have  followed  its  use,  although  Fenwick  says  that  he  has  injected  a 
dram  or  more  of  a  20  per  cent,  solution  and  never  saw  any  evil  effects. 
Having  tested  the  lamp  to  ensure  its  being  in  working  order,  the  instru- 
ment is  introduced  and  carefully  moved  about,  to  be  sure  that  the  beak 
is  not  in  contact  with  the  bladder-wall.  First  the  beak  is  directed  up- 
ward, and  then  turned  from  side  to  side  till  all  parts  of  the  bladder 
come  into  view  except  the  trigone.  The  handle  is  then  lowered  and 
the  position  of  the  beak  reversed,  bringing  within  the  field  of  vision 
the  trigone  and  the  orifices  of  the  ureters. 

In  its  normal  condition  the  mucous  membrane  of  the  bladder  is  of 


392 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


a  yellowish  or  reddish-yellow  color.  Its  blood-vessels  are  tortuous 
and  <jenerally  visible ;  the  fibers  of  the  detrusor  urinai  muscle  can  also 
be  seen,  and  they  present  a  trabecular  arrangement.  At  the  posterior 
angles  of  the  trigone  are  two  prominent  spots,  the  opening  of  the 
ureters.  Every  thirty  or  sixty  seconds,  according  to  Meyer,  fine 
streams  or  jets  of  urine  can  be  seen  escaping  from  them. 

This  examination  is  valuable,  not  only  in  revealing  a  stone,  but  also 
in  ascertaining  the  existence  of  morbid  growths,  cystitis,  and  tubercular 
disease  of  the  bladder.  Fenwick  recommends  a  cystoscope  for  intro- 
duction by  the  suprapubic  route  (Fig.  167).  This  instrument  can  be 
inserted  through  the  opening  made  by  the  trocar  and  cannula,  as  shown 
in  Fig.  165. 


Fig.   167. — Electric  cystoscope  (Fenwick). 


Composition  of  the  Stone. — When  sand  or  fragments  of  stone  come 
away  with  the  urine,  they  should  be  carefully  examined  to  determine  the 
composition  of  the  calculus.  The  results  obtained  in  this  way,  however, 
are  not  to  be  relied  upon,  for  the  urine  may  contain  phosphates  due  to 
cystitis,  while  the  nucleus  of  the  stone  may.be  composed  of  uric  acid, 
oxalate  of  lime,  or  other  ingredient. 

Under  any  of  the  following  conditions  we  may  fail  to  detect  a  stone 
that  is  lying  in  the  bladder : 

1.  The  calculus  may  be  covered  with  clotted  blood  or  mucus,  so 
that  it  feels  like  the  bladder-wall  when  touched  with  a  sound. 

2.  The  stone  may  be  so  completely  encysted  that  little  or  none  of 
its  surface  is  tangible. 

3.  It  may  be  attached  to  the  anterior  wall  of  the  bladder  by  fibrin- 
ous adhesions. 

4.  The  stone  may  lie  in  a  diverticulum  which  communicates  with 
the  main  cavity  of  the  bladder  by  only  a  small  opening. 

5.  A  stricture  or  enlarged  prostate  may  prove  a  serious  obstacle  to  a 
correct  diagnosis. 

Measuring  the  Calculus. — For  roughly  estimating  the  size  of  a  stone 
Thompson's  searcher  (Fig.  168)  is  very  convenient.  It  is  hollow  for 
the  purpose  of  withdrawing  urine  or  injecting  water  during  the  search. 
As  soon  as  a  stone  is  touched  the  collar  on  the  stem  of  the  instrument 
is  pushed  down  to  the  meatus.  The  searcher  is  then  slowly  withdrawn, 
keeping  its  point  in  contact  with  the  stone  by  gentle  tappings,  and 
marking  the  point   on  the  stem  when  contact  ceases.     The  distance 


THE    GENITO-URINARY  SYSTEM.  393 

between  this  point  and  the  collar  will  represent  the  diameter  of  the 
stone.  More  accurate  measurement  can  be  obtained  by  the  use  of  a 
small  lithotrite. 

Lest  the  young  surgeon  should  feel  too  confident  in  his  ability  to 
detect  stone,  let  me  remind  him  that  surgical  records  afford  several 
instances  in  which  the  most  experienced  surgeons  failed  to  detect  large 
calculi  which  were  afterward  found  post-mortem.  When  such  men  as 
Cheselden,  Dupuytren,  Roux,  and  Crosse  have  cut  for  stone  and  found 
none,  it  behooves  the  tyro  to  be  cautious.  It  should  also  be  borne  in 
mind  that  the  operation  of  sounding  the  bladder  is  not  free  from  danger. 


Fig.  168. — Thompson's  latest  stone-searcher. 

Fatal  cystitis  has  been  reported  by  several  writers,  but  this  was  probably 
due  to  want  of  surgical  cleanliness. 

In  most  cases  of  sounding  for  stone  an  anesthetic  should  be  given, 
as  it  relaxes  all  spasm  and  admits  of  immediate  recourse  to  operative 
procedure  without  submitting  the  patient  to  a  second  ordeal. 

Treatment. — To  dissolve  a  stone  by  the  administration  of  medicine 
or  by  the  injection  of  fluids  into  the  bladder  is  entirely  out  of  the  ques- 
tion. The  preventive  treatment  of  stone,  in  persons  who  are  persist- 
ently passing  large  quantities  of  crystals  or  who  have  inherited  a  tend- 
ency to  calculous  disease,  is  another  matter.  The  subjects  of  enlarged 
prostate,  stricture,  chronic  cystitis,  or  atony  of  the  bladder  should  be 
carefully  watched  lest  changes  in  the  composition  of  the  urine  and 
obstruction  to  its  flow  should  result  in  the  formation  of  calculi. 

A  person  who  passes  urinary  crystals,  or  who  has  had  an  attack  of 
renal  colic,  or  who  passes  habitually  urine  of  high  specific  gravity  con- 
taining uric  acid  in  excess,  should  be  very  methodical  in  his  manner  of 
living,  his  exercise,  and  his  diet.  The  urinary  tract  should  be  flushed 
out  by  drinking  large  quantities  of  water  on  retiring  and  on  rising  from 
bed,  as  well  as  between  meals.  Sugars  and  fats  should  be  avoided. 
Meat  should  not  be  eaten  more  than  once  a  day,  and  alcohol  should 
be  abstained  from.  Acids  or  alkalies  should  be  administered  as  indi- 
cated by  the  reaction  of  the  urine  and  its  chemical  composition.  Ex- 
ercise short  of  fatigue,  life  in  the  open  air,  and  avoidance  of  profuse 
perspiration  are  to  be  highly  recommended. 

When  there  is  chronic  cystitis,  atony,  prostatic  disease,  or  stricture, 
the  treatment  appropriate  to  these  conditions  respectively  should  be 
faithfully  carried  out.  Particularly  important  is  it  that  residual  urine 
should  be  disposed  of  by  the  regular  use  of  the  catheter  and  by  washing 
of  the  bladder  when  indicated. 

Removal  of  Stone. — When  once  a  stone  has  attained  a  size  too  large 
for  passage  through  the  urethra  it  must  be  disposed  of  by  operation. 
The  procedures  by  which  this  can  be  accomplished  are — 

I.  Litholapaxy  or  lithotrity ;  2.  Perineal  lithotomy,  median  or 
lateral ;   3.  Suprapubic  lithotomy. 


394  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

If  the  examination  detailed  in  the  foregoing  pages  be  complete,  it 
will  give  the  data  from  which  the  surgeon  can  decide  the  choice  of 
operation — viz.  the  age  of  the  patient,  the  presence  or  absence  of 
stricture  of  the  urethra,  the  condition  of  the  prostate  gland,  the  pres- 
ence, size,  and  composition  of  the  stone,  the  condition  of  the  bladder, 
and  the  state  of  the  kidneys. 

Litholapaxy  has  so  encroached  upon  the  fields  of  other  procedures 
that  it  must  be  regarded  as  the  operation  always  to  be  chosen  unless 
there  are  special  conditions  in  the  individual  case  which  contraindi- 
cate  it. 

Until  recent  years  the  question  of  operating  on  boys  by  crushing 
the  stone  was,  to  say  the  least,  unsettled.  In  India,  where  the  vast 
number  of  people  suffering  from  stone  affords  the  surgeons  an  unlim- 
ited experence,  litholapaxy  is  becoming  the  universal  remedy.  J.  Forbes 
Keith,  who  is  said  to  have  had  the  largest  experience  in  this  operation 
of  any  living  surgeon,  has  performed  litholapaxy  on  503  boys  w'ith  a 
result  of  4  deaths,  and  106  perineal  lithotomies  with  no  deaths — a  total 
of  609  with  4  deaths.  Freyer  reports  852  operations,  158  of  which 
were  on  boys,  with  a  fatal  result  in  2  cases.  These  and  several  other 
operators  of  large  experience  have  practically  abandoned  cutting 
operations  for  stone. 

G.  Barling  of  Birmingham  estimates  the  mortality  of  suprapubic 
lithotomy  in  patients  under  twenty  years  of  age  at  17.4  per  cent,  in  a 
total  of  72  cases.  In  61  patients  under  twenty  operated  by  litholapaxy 
the  mortality  was  5  per  cent.  Lateral  lithotomy  yields  a  mortality  of 
5  per  cent. 

In  British  and  American  practice  it  is  probably  safer  to  employ 
lateral  lithotomy  in  boys  below  ten  years  of  age,  for  two  reasons  : 
first,  because  the  rate  of  mortality  is  little  if  any  higher  than  that  fol- 
lowing litholapaxy ;  and  secondly,  because  the  use  of  the  lithotrite  is 
attended  with  considerable  risk  in  the  hands  of  those  who  have  not 
had  a  large  experience. 

In  adults  there  can  be  no  question  that  litholapaxy  is  the  operation 
par  excellence,  and  yet  there  are  certain  conditions  in  which  it  is  contra- 
indicated — viz. : 

1.  The  existence  of  a  stricture  which  cannot  be  dilated.  In  this 
instance  a  median  lithotomy  is  the  procedure  to  be  chosen,  for  it  will 
dispose  of  both  stricture  and  stone. 

2.  Some  cases  of  enlarged  prostate  complicated  with  chronic  cystitis 
and  a  large  stone.  In  this  class  suprapubic  lithotomy  is  the  operation 
of  choice. 

3.  In  atony  of  the  bladder  where  there  is  a  considerable  quantity  of 
residual  urine  and  a  corresponding  want  of  expulsive  power.  Perineal 
lithotomy,  except  in  the  case  of  a  very  large  stone,  will  give  the  best 
results.  If  the  stone  is  large,  it  can  be  crushed  by  introducing  an 
instrument  through  the  perineal  wound  (^perineal  lithotomy). 

4.  Rare  cases  in  which  the  stone  is  of  moderate  size,  and  of  such 
hardness  and  density  that  the  lithotrite  cannot  stand  the  strain  of 
crushing  it.  W.  S.  Forbes  of  Philadelphia  has  found  by  experiments 
upon  184  vesical  calculi  that  the  majority  of  stones  are  crushed  by  a 
pressure  of  less  than  one  hundred  pounds ;  one  of  the  stones  required 


THE    GENITOURINARY  SYSTEM. 


395 


a  pressure  of  four  hundred  and  six  pounds  to  crush  it.  He  has,  as  a 
result  of  these  experiments,  devised  a  Hthotrite  of  greater  crushing 
power  than  that  of  the  instruments  now  in  use. 

The  Operation. — Early  diagnosis  is  of  the  utmost  importance  in  the 
treatment  of  urinary  calculus.  If  detected  while  the  stone  is  yet  small 
and  before  serious  changes  in  the  bladder  and  the  composition  of  the 
urine  have  set  in,  litholapaxy  is  a  safe  operation  and  one  that  should 
supplant  every  other  device. 

The  operation  of  lithotrity  consists  in  crushing  the  stone  at  one  or 
more  sittings  and  allowing  the  debris  to  come  away  with  the  natural 
discharge  of  the  urine.  This  operation  is  no  longer  practised.  In 
1878  the  late  Professor  Bigelow  devised  and  perfected  a  plan  of  per- 
forming lithotrity  at  a  single  operation  by  crushing  the  whole  of  the 
stone  and  abstracting  all  of  the  fragments  and  debris  by  an  effective 
evacuating  apparatus.     This  operation  is  the  one  followed  universally 


Fig.  169. — Non-fenestrated  lithotrites. 


at  the  present  day.  Lithotrites  are  made  of  different  sizes  and  lengths. 
Fig.  169  represents  smooth-bladed  or  non-fenestrated  lithotrites  suit- 
able for  crushing  small  stones  of  only  moderate  hardness.     Fig.   170 


Fig.  170. — Fenestrated  jaws  of  lithotrite. 


represents  a  fenestrated  instrument  heavier  and  stronger  than  the  pre- 
ceding and  adapted  to  large  stones  of  great  density  and  hardness.  On 
account  of  its  general  adaptability  it  is  the  only  form  employed  by 
many  operators. 

Chismore  of  San  Francisco  has  improved  the  modern  instrument  by 
devising  a  tip  by  means  of  which  fluid  can  be  thrown  into  the  bladder 
while  the  instrument  is  in  position.  By  this  means  a  commotion  in  the 
waters  is  produced  which  brings  the  fragments  within  the  grasp  of  the 
instrument  (Fig.   171). 


396 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


Lithotritcs  are  so  constructed  as  to  allow  the  male  blade  to  slide 
within  the  female  blade  and  to  crush  the  stone  by  their  approximation. 
A  button  on  the  handle  regulates  the  movement  until   the  stone  is 


Fig.  171. — Chismore's  evacuating  lithotrite. 


found  and  grasped ;  the  operator  then,  without  moving  his  hands, 
applies  the  more  powerful  mechanism  by  which  the  stone  is  crushed. 
Bigelow's  lithotrite  is  provided  with  a  corrugated  ball  handle ;  other 
instruments  have  a  wheel  which  is  turned  by  the  thumb  and  finger  of 
the  operator's  right  hand. 

After  the  stone  is  crushed  an  evacuating  apparatus  is  necessary  for 
the  removal  of  the  fragments  and  debris.  Bigelow's  evacuator  is 
represented  in  Fig.   172.     An  evacuating  catheter  with  a  large  eye, 


Fig.  172. — Bigelow's  latest  evacuator. 

devised  by  Harrison,  is  represented  in  Fig.  173.  Chismore's  washing- 
bottle  (Fig.  174)  is  hght,  easily  handled,  and  less  expensive  than  those 
hitherto  in  use. 

Preparation  of  the  Patient. — The  practice  of  "  educating "  the 
urethra  by  passing  large-sized  instruments  for  days  prior  to  the  ope- 
ration is  now  abandoned.     The  patient   should  be  kept  in  bed  for  two 


THE    GENITO-URINARY  SYSTEM.  397 

or  three  days  to  lessen  as  much  as  possible  the  irritation  caused  by  the 
calculus  and  to  allow  vesical  irrigation  to  be  carried  out  if  required. 
The  bladder  should  be  rendered  as  nearly  aseptic  as  possible.  If  the 
urine  is  healthy,  this  point  is  already  gained,  for  the  normal  urine  of 


Fig.  173. — Harrison's  evacuator  with  large  eye. 

the  bladder  is  free  from  septic  germs.  In  the  presence  of  cystitis  or 
suppuration  in  the  kidney  the  urine  is  filled  with  septic  micro-organisms 
and  requires  disinfection.  It  should  be  drawn  off  every  eight  hours, 
and  the  bladder  washed  out  with  Thiersch's  solution  or  with  a  solution 


Fig.  174. — Chismore's  evacuator. 

of  nitrate  of  silver  of  the  strength  of  one  grain  to  the  ounce.  Ben- 
zoate  of  sodium,  salicylic  acid,  or  salol  given  by  the  mouth  will  aid  in 
bringing  the  urine  into  better  condition.  The  patient's  bowels  should 
be  moved  by  a  laxative  the  night  previous,  and  washed  out  with  an 
enema  four  hours  before  the  operation.  The  pubes  and  perineum  should 
be  shaved,  scrubbed  with  soap  and  water,  and  prepared  exactly  as  if  the 
patient  were  about  to  undergo  a  cutting  operation,  and  when  placed 
upon  the  table  sterilized  towels  should  be  arranged  around  the  parts  to 
guard  against  the  possibility  of  carrying  infection  to  the  urethra  by  the 
lithotrite  or  hand  of  the  operator.  The  limbs  should  be  encased  in 
flannel  leggings  and  the  patient  kept  warm  while  in  the  operating-room. 
If  the  prostate  is  large  and  the  stone  lodged  in  a  pouch  behind  it,  Har- 
rison recommends  turning  the  patient  over  on  his  belly  after  he  is 
anesthetized  and  slightly  concussing  his  body.  Stones  are  thus  made 
to  fall  out  of  a  pouch  into  the  cavity  of  the  bladder.  A  small  sponge, 
secured  by  a  tape,  is  then  placed  in  the  rectum  to  prevent  the  return  of 
the  calculus  to  its  pouch.  Even  the  warmest  advocates  of  ether  will 
admit  that  chloroform  should  be  given  when  there  is  disease  of  the 
kidneys.  Another  reason  against  the  use  of  ether  is  the  fact,  first 
noticed  by  Lawson  Tait,  that  it  sometimes  entirely  arrests  the  secretion 
of  urine.  After  being  anesthetized  the  patient  is  placed  with  his  pelvis 
on  a  pillow  and  the  bladder  given  a  final  washing  with  Thiersch's  solu- 


398 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


tion,  Icavinf^  six  or  eight  ounces  within  it  to  facilitate  the  movements 
of  the  hthotrite. 

The  operator,  standing  at  the  patient's  right  side,  introduces  the 
instrument  as  he  would  a  sound,  and  with  the  utmost  gentleness  begins 
his  search  for  the  stone.  He  may  begin  by  pushing  the  instrument  to 
the  back  wall  and  withdrawing  the  male  blade  until  the  neck  of  the 
bladder  arrests  it.  In  many  cases  the  stone  will  fall  directly  between 
the  blades  at  the  end  of  this  movement.  The  instrument  is  then  made 
to  grasp  the  stone,  and  after  gently  rotating  it  to  make  sure  that  the 
bladder-wall  is  not  caught  in  the  instrument,  the  work  of  crushing 
begins.  Sometimes  it  is  necessary  to  turn  the  beak  of  the  Hthotrite 
backward  and  pick  up  the  stone  from  behind  the  prostate.  The 
greatest  care  should  be  observed  lest  the  bladder-wall  be  caught  in  the 
grasp  of  the  instrument,  and  this  is  most  likely  to  occur  in  cases  com- 
plicated with  enlarged  prostate.     Fig.  175  represents  a  condition  which 


Fig.  175. — Wall  of  the  bladder  caught  between  the  blades  of  the  Hthotrite. 

is  very  apt  to  lead  to  an  accident  of  this  kind.  The  female  blade  is  in 
proper  contact  with  the  stone,  but  the  male  blade  is  in  a  pouch  behind 
the  enlarged  prostate.  If  the  blades  be  brought  together  in  this 
relation  of  the  parts,  the  bladder  will  suffer.  Gentle  rotation  before 
applying  any  crushing  force  is  always  sufficient  to  detect  this  false 
position.  About  fifteen  or  twenty  minutes  are  sufficient  for  picking  up 
and  crushing  the  fragments  of  calculus.  The  blades  are  then  brought 
closely  together,  the  instrument  withdrawn,  and  the  ev^acuation  begun. 
An  evacuating  catheter  of  about  28  (French)  caliber  is  suitable  for  an 
adult.  The  bulb  is  attached,  the  stopcock  turned,  and  the  bulb  com- 
pressed. If  the  tube  becomes  blocked  with  a  fragment,  the  bulb  will 
cease  to  expand,  but  a  quick,  forcible  pressure  readily  brings  matters 
right.  The  wall  of  the  bladder  may  be  sucked  into  the  eye  of  the 
evacuating  catheter,  causing  the  "  fish-bite,"  so  called.  Bigelow 
attributed  this  to  want  of  sufficient  fluid  in  the  bladder,  and  advised  the 
injection  of  several  ounces  more. 

One  of  the  mishaps  likely  to  occur  in  the  operation  is  clogging  of 
the  blades  of  the  Hthotrite  with  fragments  and  debris,  so  that  the  instru- 


THE    GENITO-URINARY  SYSTEM.  399 

merit  cannot  be  withdrawn.  This  is  less  Hkely  to  occur  when  the  fenes- 
trated instrument  is  the  kind  employed.  If  ordinary  efforts  fail  to  bring 
the  blades  together,  the  beak  should  be  pressed  up  against  the  supra- 
pubic region  and  cut  down  upon  as  in  suprapubic  lithotomy,  or  it  can 
be  made  to  protrude  at  the  perineum  and  a  lateral  or  median  cystotomy 
performed.  After  the  blades  are  freed  and  the  instrument  withdrawn, 
the  evacuation  of  remaining  fragments  is  effected  by  the  incision.  If 
during  the  employment  of  the  lithotrite  the  bladder  makes  violent 
expulsive  efforts,  the  operator  should  immediately  suspend  all  manip- 
ulations until  these  contractions  cease,  lest  injury  be  done  to  the 
bladder. 

Accidents  are  liable  to  happen  in  the  course  of  this  operation,  and 
it  is  well  to  be  prepared  for  them.  Reference  has  already  been  made 
to  clogging  of  the  blades  so  as  to  prevent  their  withdrawal.  On  account 
of  this  and  similar  dangers  the  operator  should  have  everything  in 
readiness  to  make  a  lithotomy.  The  lithotrite  in  contact  with  a  very 
hard  stone  may  break  or  one  of  its  blades  may  bend,  thus  preventing 
its  withdrawal.  The  eye  of  the  evacuating  catheter  may  be  filled  with 
stone  fragments  whose  projecting  sharp  angles  would  lacerate  the  ure- 
thra in  any  attempt  at  withdrawal.  A  stylet  is  generally  sufficient  to 
dislodge  the  fragments,  and  should  always  be  at  hand. 

Fragments  of  stone  may  be  forced  by  strong  contractions  of  the 
bladder  into  the  deep  urethra,  and  become  so  firmly  impacted  as  to 
resist  all  attempts  to  push  them  back.  In  such  a  case  a  median 
cystotomy  should  be  undertaken,  using  as  a  guide  the  fragment  itself, 
or  a  small  staff  if  it  can  be  pushed  past  the  obstruction  into  the  bladder. 

Injury  to  the  soft  parts  by  the  lithotrite  or  by  fragments  of  stone  is 
always  attended  wdth  danger,  and  should  be  most  carefully  guarded 
against.  Rupture  of  the  bladder  has  occurred  in  cases  where  the 
walls  of  the  viscus  were  thin  and  under  strong  expulsive  efforts. 
When  the  rent  is  recognized  as  involving  the  peritoneal  side  of  the 
bladder,  no  time  should  be  lost  in  making  a  celiotomy  and  stitching 
up  the  wounds  in  the  bladder-wall. 

Aftcr-trcatJHoit — The  last  fragment  having  been  removed,  the  blad- 
der should  be  washed  out  wath  w^arm  boric-acid  solution  until  the  fluid 
returns  free  from  discoloration  with  blood.  If  the  urine  does  not  come 
away  at  proper  intervals,  the  catheter  should  be  judiciously  employed. 
After  a  prolonged  operation,  and  especially  if  the  bladder  is  irritable, 
a  suppository  of  morphin  may  be  used  with  advantage.  The  case 
should  be  watched,  and  if  any  symptoms  arise  to  indicate  that  the 
bladder  still  contains  fragments,  these  should  be  dealt  with  imme- 
diately. Not  until  the  urine  is  normal  in  character  should  the  patient 
be  dismissed  as  cured. 

Lithotomy. — The  field  of  this  classical  and  time-honored  operation 
has  become  so  limited  that  it  promises  ere  long  to  become  only  a 
memory.  Although  a  few  operators  have  practically  abandoned  lith- 
otomy for  the  universal  use  of  the  lithotrite,  the  surgeons  of  Europe 
and  America  are  likely  for  some  time  at  least  to  accord  this  "  master 
handwork  of  surgery "  a  place.  The  bladder  can  be  incised  for  the 
removal  of  stone  from  two  nearly  opposite  directions,  the  perineum 
and  the  suprapubic  region. 


400  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

I .  Perineal  LitJiotoviy. — When  a  cutting  operation  is  decided  on  the 
perineal  route  has  the  following  advantages:  i.  It  affords  a  ready  and 
fairly  commodious  access  to  the  bladder  through  structures  that  are 
tolerant  of  operative  measures,  and  allows  the  surgeon  to  remove  a 
stone  of  considerable  size  and  satisfy  himself  that  no  stone  or  fragments 
are  left  behind.  2.  It  secures  drainage,  constant  and  complete,  from 
the  most  dependent  portion  of  the  bladder,  3.  It  is  attended  with  a 
low  rate  of  mortality,  especially  in  boys. 

The  size  of  the  stone  is  about  the  only  limit  to  the  applicability  of 
the  operation  :  a  rule  which  is  almost  universally  approved  of  is  that  a 
stone  over  an  inch  and  a  quarter  in  diameter,  if  taken  away  whole, 
should  not  come  out  below  the  symphysis  pubis ;  from  this  limit 
Keyes  expresses  his  willingness  to  cut  off  the  last  quarter  of  an 
inch. 

(<?)  The  Lateral  Operation. — The  patient,  having  been  prepared  as 
for  the  operation  of  litholapaxy,  is  anesthetized  and  kept  in  the  lith- 
otomy position  by  Clover's  crutch  or  by  securing  the  hands  to  the  feet 
by  means  of  bandages,  and  then  confided  to  two  assistants,  one  stand- 
ing on  each  side  of  the  table.  The  staff  is  introduced  and  handed  to 
an  assistant,  W'ho  holds  it  up  with  the  right  hand  and  the  scrotum  with 
the  left.  The  bladder  should  contain  three  or  four  ounces  of  urine  or 
boric-acid  solution.  The  incision  should  commence  in  the  raphe  of  the 
perineum  one  inch  in  front  of  the  anus,  and  the  knife  should  be  pushed 
through  the  tissues  steadily  toward  the  staff,  so  as  to  touch  it  in  the 
membranous  portion  of  the  urethra  below  the  line  of  the  bulb.  The 
direction  of  the  wound  is  downward  and  outward  about  midway 
between  the  anus  and  tuberosity  of  the  ischium  for  two  inches  or 
more  according  to  the  size  of  the  stone.  The  tissues  are  divided  as 
the  knife  is  withdrawn,  and  in  such  a  way  that  the  depth  of  the  incis- 
ion is  gradually  diminished  until  it  reaches  its  posterior  termination. 
The  groove  in  the  staff  is  now  sought  by  the  fore  finger  of  the  left 
hand.  With  this  as  a  guide  the  operator  inserts  the  point  of  the  knife 
into  the  groove,  and  grasps  the  staff  in  his  left  hand  to  satisfy  himself 
that  it  is  exactly  in  the  middle  line  close  up  against  the  pubis.  He  then 
returns  it  to  the  assistant,  and  cautiously  pushes  on  the  knife  through 
the  groove,  keeping  the  edge  directed  obliquely  outward  so  as  to  divide 
the  prostate  in  its  greater  radius.  The  entrance  of  the  knife  into  the 
bladder  is  announced  by  a  gush  of  the  fluid  which  the  viscus  contains. 
The  operator  next  inserts  his  finger  into  the  bladder,  directs  the  assist- 
ant to  withdraw'  the  staff,  and,  using  his  finger  as  a  guide,  introduces 
the  forceps.  He  searches  for  the  stone  with  the  blades  closed,  and 
having  found  it  opens  them  very  wide,  depresses,  and  then  closes  them. 
By  gently  relaxing  his  hold  and  renewing  it  he  shifts  the  position  of 
the  calculus  if  unfavorable  for  extraction,  and  with  the  assistance  of 
his  left  fore  finger  proceeds  to  draw  out  the  stone,  not  directly,  but  by  a 
motion  in  alternate  directions,  so  as  to  dilate  the  margin  of  the  wound 
without  tearing.  Forcible  efforts  ought  never  to  be  used  in  doing  this, 
and  it  is  much  better  to  introduce  the  knife  again  if  the  opening  proves 
too  small.  After  one  stone  has  been  removed  the  bladder  ought  to  be 
searched  for  more  with  a  sound  introduced  through  the  wound,  and  if 
any  are  detected  they  must  be  removed  in  the  same  way  as  the  first. 


THE    GENITO-URINARY  SYSTEM.  4OI 

Should  the  calculus  be  broken,  its  fragments  must  be  carefully  extracted 
with  the  scoop  if  small,  or  by  the  forceps  if  large  (Syme). 

The  old  operators  were  very  expert  in  performing  this  operation,  as 
it  has  been  done  in  less  than  a  minute.  This  was  a  desideratum  only 
in  preanesthetic  days.  Now-a-days  our  aim  should  be  to  take  time  to 
do  an  operation  well ;  the  few  extra  minutes  saved  at  the  operation  may 
be  lost  at  the  funeral.  After  removal  of  the  stone  the  bladder  should 
be  explored  for  the  calculi,  and  the  best  instrument  for  this  purpose  is 
the  finger  aided  by  pressure  over  the  hypogastrium.  Failing  to  reach 
the  distant  parts  of  the  bladder,  an  ordinary  sound  may  replace  the 
finger.  All  bleeding  having  been  arrested,  a  drainage-tube  is  inserted 
into  the  bladder,  through  which  a  stream  of  warm  boric-acid  solution 
is  allowed  to  flow  until  the  fluid  comes  back  clear.  The  wound  is 
lightly  packed  with  strips  of  iodoform  gauze,  to  be  changed  at  frequent 
intervals,  and  the  patient  placed  in  bed,  lying  on  the  left  side  with  the 
knees  and  hips  flexed.  The  arteries  divided  in  the  operation  are  usually 
the  transverse  perineal  and  the  hemorrhoidal.  These  can  be  at  once 
grasped  with  hemostatic  forceps,  and  ligated  later  if  necessary.  The 
artery  of  the  bulb  may  bleed  freely,  and  should  be  ligated  or  com- 
pressed with  forceps,  which  can  be  left  in  position  for  thirty-six  hours. 
Sometimes  a  copious  oozing  takes  place  from  the  prostate,  for  which 
pressure  may  be  required,  either  by  packing  around  a  catheter  en 
chemise  or  by  the  dilatable  tampon  of  Buckston  Browne. 

The  deep  portion  of  the  urethra  may  bleed  in  a  troublesome  man- 
ner, but  this  can  be  arrested  by  distending  the  rectum  with  a  plug  or 
air-bag,  care  being  taken  not  to  interfere  with  drainage  from  the  blad- 
der. The  drainage-tube  may  be  removed  at  the  end  of  two  or  three 
days.  Urine  begins  to  come  through  the  urethra  about  the  ninth  day, 
and  by  the  thirteenth  or  fifteenth  day  the  flow  by  the  perineum  entirely 
ceases.  During  the  after-treatment  the  food  should  be  predigested  as 
much  as  possible  in  order  that  no  action  of  the  bowel  may  be  required 
for  several  days. 

{b)  The  Median  Operation  {Median  Lithotoni)). — This  is  much  the 
simplest  of  the  cutting  operations  for  stone,  being  merely  an  extension  of 
the  operation  for  drainage  of  the  bladder.  The  patient  is  placed  in  the 
same  position  as  for  lateral  lithotomy,  and  a  staff  grooved  in  the  middle 
line  is  inserted  and  held  up  under  the  pubes.  The  incision  is  made  in 
the  raphe  between  the  scrotum  and  the  anus,  and  the  parts  divided  until 
the  membranous  portion  of  the  urethra  is  exposed.  The  point  of  the 
knife  is  then  made  to  enter  the  groove  in  the  staff,  and  the  urethra  is 
divided  back  for  about  three-quarters  of  an  inch.  Through  this  open- 
ing the  finger  is  introduced,  and  by  a  boring  or  rotary  motion  the  blad- 
der is  reached.  The  staff  is  now  withdrawn  and  forceps  conducted  in 
to  the  stone,  which  is  removed  as  in  lateral  lithotomy.  The  simplicity 
of  this  operation  is  its  strongest  point :  no  vessels  of  any  consequence 
are  divided,  the  ejaculatory  ducts  are  not  injured,  and  the  probability 
of  urinary  infiltration  is  lessened.  Its  sphere  is  exceedingly  limited 
(except  as  it  forms  a  part  of  the  operation  of  perineal  lithotrity,  next 
to  be  described).  It  is  adapted  to  small  stones,  which  can  more  easily 
be  diposed  of  by  litholapaxy.  When  it  is  deemed  necessary  to  enlarge 
the  opening  into  the  bladder  for  the  purpose  of  removing  a  large  stone, 

26 


402 


SURGICAL    DIAGNOSIS  AND    TKEATMENT. 


the  followinc;^  method  can  be  adopted  :  Pass  the  finger  through  the 
wound  into  the  bladder,  and,  using  it  as  a  guide,  carry  a  curved  probe- 
pointed  knife  through  the  membranous  portion  of  the  urethra  ;  turn  the 
bhide  directl)'  backward,  and  cut  in  the  middle  line  as  much  of  the 
perineum  as  may  be  required.  Still  further  room  may  be  gained  by 
carrying  the  probe-pointed  bistoury  well  into  the  bladder,  guided  by 
the  finger  as  before,  turning  the  edge  toward  the  rectum,  and  dividing 
the  floor  of  the  prostate  from  within  outward,  commencing  at  the 
depression  which  exists  at  the  beginning  of  the  urethra  (Harrison). 

2.  Perineal  LitJiotrity. — This  operation,  introduced  by  Dolbeau  of 
Paris  in  1862,  consists  in  opening  the  membranous  portion  of  the  urethra 
as  in  median  hthotomy,  dilating  the  prostatic  opening  and  neck  of  the 


Fig.  176. — Dolbeau's  straight  crushing  forceps. 


Fig.  177. — Dolbeau's  curved  crushing  forceps. 


Fig.  178. — Gouley's  double-lever  lithoclast. 

bladder,  crushing  the  stone,  and  immediately  extracting  the  fragments. 
Dolbeau's  straight  (Fig.  176)  and  curved  crushing  forceps  (Fig.  177) 
may  be  used,  or  Gouley's  double-lever  lithoclast  (Fig.  178).  The  frag- 
ments are  removed  by  evacuating  catheters  passed  through  the  wound. 
This  operation  has  met  with  a  good  deal  of  favor,  and  has  the 
following  points  to  recommend  it:  i.  It  is  less  dangerous  than 
other  cutting  operations,  and  is  especially  suitable  for  old  and  feeble 
persons.  2.  It  admits  of  the  crushing  and  removal  of  large  and  hard 
calculi  in  a  short  space  of  time.  3.  The  route  to  the  bladder  being 
shorter  and  of  larger  caliber,  catheters  of  greater  size  can  be  used  than 
in  litholapaxy,  and  more  complete  washing  out  and  drainage  of  the 
bladder  can   be    effected.       4    It    enables   the    operator  to   deal   with 


THE    GENITOURINARY  SYSTEM.  4O3 

cystitis,  atony  of  the  bladder,  and  some  diseased  conditions  of  the 
prostate.  5.  There  is  less  danger  of  a  recurrence  of  calculus,  owing 
to  the  ease  with  which  the  bladder  can  be  kept  free  from  ammoniacal 
urine. 

3.  Suprapubic  LitJiotoiny. — The  patient  is  placed  in  the  ordinary 
recumbent  position  w^ith  the  thighs  slightly  flexed,  or  the  Tredelenburg 
position  may  be  employed,  the  pubes  shaved,  and  the  field  of  operation 
disinfected.  A  rubber  bag  with  a  smooth  surface  and  capable  of  hold- 
ing about  twelve  ounces  of  water  is  inserted  into  the  rectum  and 
distended  with  warm  water.  For  the  majority  of  cases  ten  ounces  is 
sufficient ;  for  young  patients  a  less  quantity  will  suffice.  This  disten- 
tion of  the  rectum  is  unnecessary  if  the  Trendelenburg  position  is 
employed,  and  I  cannot  help  thinking  that  its  value  is  doubtful  in  any 
case.  Theoretically  it  pushes  the  peritoneum  above  the  bladder  in 
front,  and  lessens  the  risk  of  wounding  it.  If  the  operator  take  the 
precaution  to  hook  up  the  tissues  at  the  upper  angle  of  the  incision,  he 
will  push  the  peritoneum  out  of  harm's  way  and  probably  never  see  it. 
Whether  the  rectal  bag  is  used  or  not,  the  bladder  should  be  well 
w'ashed  out  with  warm  boric-acid  solution  injected  through  a  soft-rub- 
ber catheter  connected  with  a  fountain  syringe  or  irrigator.  At  the 
close  of  the  washing  a  few  ounces  of  the  boracic  solution  are  allowed 
to  remain  in  the  bladder.  The  fountain  is  then  handed  to  an  assistant, 
who  by  lowering  or  raising  can  regulate  the  amount  of  distention  as  the 
surgeon  directs.  The  incision  is  made  exactly  in  the  middle  line, 
beginning  just  above  the  pubic  symphysis  and  extending  toward  the 
umbilicus  for  two  or  three  inches.  After  cutting  through  skin  and 
subcutaneous  tissue  the  sheath  of  the  rectus  is  exposed  and  divided  on 
a  director;  the  layer  of  transversalis  fascia  bounding  the  prevesical 
space  comes  next  to  view.  Immediately  behind  the  posterior  layer  of 
this  fascia  is  the  perineum.  The  fore  finger  of  the  left  hand  should 
now  hook  up  the  tissues  above  the  upper  portion  of  the  dissection  in 
order  to  draw  up  the  peritoneum  toward  the  umbilicus.  If  it  becomes 
visible,  it  can  be  pushed  up  directly  by  the  finger.  There  is  generally 
some  loose  adipose  tissue  in  front  of  the  anterior  wall  of  the  bladder ; 
in  separating  this  care  should  be  taken  not  to  wound  any  of  the  veins 
which  ramify  in  it.  After  tearing  an  opening  in  the  fat  the  assistant 
elevates  the  irrigator,  and  as  the  bladder  dilates  it  will  be  seen  to  rise 
up  into  the  wound.  A  needle  carrying  a  stout  silk  thread  should  be 
passed  through  its  wall,  and  then  it  can  be  opened  by  inserting  the 
knife  in  the  middle  line  and  making  the  incision  upward  for  about  three- 
quarters  of  an  inch.  The  finger  is  passed  through  this  opening  and 
the  bladder  explored.  In  making  the  incision  care  should  be  taken  to 
pass  the  knife  with  a  quick  motion  through  the  entire  thickness  of  the 
bladder-wall,  lest  the  mucous  membrane  be  pushed  before  the  point  of 
the  knife  and  the  bladder  be  only  partially  incised.  If  the  opening  is 
found  too  small,  the  incision  can  be  extended.  Guided  by  the  finger, 
a  small  pair  of  forceps  is  now  introduced  into  the  bladder  and  the  stone 
extracted. 

The  treatment  of  the  wound  must  depend  upon  the  condition  of  the 
urine  and  the  walls  of  the  bladder.  The  opening  can  be  immediately 
closed  and  an  attempt  made  to  obtain  healing  by  first  intention  if  the 


404  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

patient  is  yoLin<^,  the  urine  healthy,  and  the  bladder  free  from  bruising 
or  not  thinned  by  disease.  Two  layers  of  sutures  should  be  used — 
one  through  the  muscular  coat  to  bring  the  edges  together,  the  other 
a  row  of  Lcmbert  sutures  an  eighth  of  an  inch  ajDart  and  going  a 
slight  distance  beyond  each  end  of  the  incision.  The  material  used 
may  be  either  silk  or  chromicized  catgut. 

It  would  be  unwise  to  attempt  immediate  union  of  the  bladder  if  the 
following  conditions  exist:  ammoniacal  urine,  diseased  kidneys, thin  or 
bruised  or  fasciculated  bladder-walls.  Under  any  of  these  conditions 
the  wound  in  the  bladder  should  be  kept  entirely  open,  and  if  the 
abdominal  wound  is  long,  it  can  be  shortened  by  one  or  two  stitches  at 
the  upper  end.  The  pressure  of  the  abdominal  organs  keeps  the  blad- 
der empty,  and  all  the  treatment  necessary  for  the  wound  is  the  appli- 
cation of  absorbent  antiseptic  dressings  frequently  changed ;  or 
Guyon's  double  drainage-tube  may  be  used,  which  is  simply  two  rub- 
ber catheters  connected  together,  through  one  of  which  irrigations  of 
boric  acid  or  other  mild  disinfecting  fluid  can  be  made  while  the  urine 
is  carried  off  into  a  receiving  bottle  by  the  other. 

The  suprapubic  operation  is  indicated  when  the  calculus  is  believed 
to  be  too  large  for  removal  by  the  perineal  route  or  too  hard  to  be 
crushed  with  the  lithotrite.  It  is  also  valuable  when  there  is  good 
evidence  that  the  stone  is  sacculated.  With  an  enlarged  prostate^ 
necessitating  the  use  of  a  catheter,  and  the  bladder  containing  a  large 
body  of  residual  urine,  the  suprapubic  operation  is  valuable. 

For  the  removal  of  stone  from  the  female  bladder  suprapubic  cys- 
totomy has  proved  very  satisfactory,  and  especially  when  the  calculus 
has  formed  around  some  foreign  body,  as  a  hair-pin,  introduced  by  way 
of  the  urethra. 

The  accidents  that  are  liable  to  occur  in  the  course  of  this  opera- 
tion are  fewer  than  by  the  perineal  incisions.  The  rectum  has  been 
lacerated  and  even  ruptured  by  the  rubber  bag,  and  the  bladder  has 
been  ruptured  by  excessive  dilatation.  Opening  of  the  peritoneum 
should  not  happen  in  the  hands  of  the  surgeon  who  is  in  the  habit  of 
recognizing  and  dealing  with  this  membrane  in  abdominal  technique. 
When  this  accident  has  happened  the  operation  has  had  to  be  post- 
poned. An  inconvenient  and  annoying  sequel  of  the  operation  is  a 
failure  of  the  wound  to  completely  close,  resulting  in  the  formation  of 
a  urinary  fistula.  This  may  be  simply  delayed  healing,  which  can  be 
rectified  by  the  application  of  nitrate  of  silver  or  the  touch  of  a  cautery 
wire.  When  the  opening  is  small  the  patient  should  be  taught  to  close 
it  with  his  finger  during  micturition.  In  intractable  cases  the  bladder 
should  be  opened  in  the  middle  line  at  the  membranous  portion  of  the 
urethra  and  a  rubber  drainage-tube  inserted.  While  the  urine  is  being 
drained  off  in  this  manner  the  fistula  can  be  made  to  heal. 

A  suprapubic  operation  is  of  great  value  in  the  removal  of  growths 
from  the  bladder  and  tumors  of  the  prostate  which  encroach  upon  the 
bladder,  in  the  removal  of  foreign  bodies,  and  in  all  cases  in  which  it  is 
necessary  to  make  a  thorough  inspection  of  the  interior  of  the  viscus. 

Tumors  of  the  Bladder. — The  tumors  which  affect  the  bladder 
are  the  following : 

I.  Papillomata. — These  deserve  the  first  place,  as  they  form  a  large 


THE    GENITO-URINARY  SYSTEM.  405 

majority  of  the  growths  met  with.  Some  authors  object  to  the  name, 
on  the  ground  that  the  mucosa  of  the  bladder  contains  no  papillae,  and 
therefore  it  cannot  be  the  seat  of  a  papilloma.  Virchow  and  others 
employ  the  term  vascular  papillomatous  fibroma  as  more  accurately 
describing  their  character.  The  name  "  villous  tumors  "  is  sometimes 
applied,  and  occasionally  "  villous  cancer  "  is  improperly  used  in  de- 
scribing them.  Like  warty  growths  elsewhere,  the  papillomata  are 
found  in  the  vicinity  of  the  urethral  and  ureteral  openings.  The  tumor 
is  composed  of  long,  delicate  filaments  forming  a  cauliflower-like  growth, 
which  is  more  or  less  dense  according  to  the  amount  of  fibrous  tissue 
which  it  contains.  The  growth  is  confined  to  the  superficial  layers 
of  the  mucous  membrane.  There  can  be  no  doubt  that  a  papilloma 
has  a  tendency  to  become  cancerous  if  not  freely  removed  at  an 
early  stage,  or  if  it  returns  and  becomes  more  and  more  fibrous  in 
its  structure. 

2.  Myouiata,  like  those  found  in  the  uterus  and  prostate,  are  largely 
composed  of  unstriped  muscular  fiber.  Sometimes  fibrous  tissue  enters 
largely  into  their  composition,  so  that  the  term  fibro-myoma  is  more 
applicable. 

3.  Fibromata  and  myomata  are  practically  the  same,  and  constitute 
the  bulk  of  the  polypi  found  in  the  bladder. 

4.  The  malignant  growths  are  sarcomata  and  carcmomata.  Sar- 
coma of  the  bladder  is  very  rare.  The  tumor  is  usually  small,  although 
in  one  case  reported  by  Mr.  Eve  the  growth  was  large  and  partially 
filled  the  bladder.  The  round-celled  variety  is  the  form  usually  met 
with.  Carcinoma  is  found  in  the  form  of  epithelioma  and  glandular- 
celled  carcinoma.  Epithelioma  is  usually  an  infiltration  of  the  bladder- 
wall,  but  it  may  occur  in  the  form  of  one  or  more  tumors.  The  disease 
is  apt  to  spread  to  the  prostate  and  neighboring  tissues,  not  uncom- 
monly showing  itself  in  the  perineum,  especially  when  it  recurs  after  an 
operation  through  the  perineum,  in  which  case  the  cicatricial  tissue 
favors  the  recurrence  of  the  growth. 

Symptoms. — Two  symptoms  are  prominent  in  tumors  of  the  bladder 
— viz.  irritability  and  hemorrhage.  The  presence  of  a  fibrous  or  carci- 
nomatous growth  gives  rise  to  frequent  micturition,  which  after  a  vari- 
able time  is  followed  by  change  in  the  urine  and  all  the  symptoms  of 
well-marked  cystitis  ;  hematuria  becomes  a  marked  feature  at  a  later 
period.  In  the  case  of  papillomata  hemorrhage  may  be  a  marked 
symptom  from  the  first,  for  papillomata  bleed  easily.  A  sudden  gush 
of  bright  blood  at  the  end  of  urination  is  sometimes  the  first  symptom, 
and  it  is  very  significant.  After  this  it  may  not  appear  for  a  long  time. 
The  pain  of  a  papillomatous  tumor  is  not  nearly  so  great  as  that  of 
carcinoma,  especially  when  the  latter  has  reached  the  stage  of  ulcer- 
ation. If  after  passing  a  sound  into  the  bladder  an  unreasonable 
amount  of  blood  comes  away  by  the  urethra,  we  may  strongly  sus- 
pect a  papillomatous  tumor,  and  its  position  is  likely  to  be  at  one  or 
more  of  the  vesical  orifices — viz.  in  the  trigone,  near  the  urethra,  or  at 
one  of  the  ureteral  orifices.  Should  we  meet  with  a  persistent  cystitis 
without  the  presence  of  a  calculus  or  without  the  history  of  infection, 
as  by  the  passage  of  an  unclean  catheter,  a  diagnosis  of  fibrous  or 
cancerous  tumor  would  be  reasonable.    In  the  examination  of  the  urine 


4o6 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


careful  microscopical  search  should  be  made  for  shreds  or  portions  of 
a  tumor. 

Tissue  for  this  examination  may  be  obtained  by  washing  out  the 
bladder  with  a  large-eyed  catheter  having  sharp  edges  at  its  opening. 
After  moderately  distending  the  bladder  the  patient  makes  a  violent 
effort  to  urinate  with  the  idea  that  a  portion  of  the  growth  might  be 
caught  in  the  eye  of  the  catheter  and  brought  away. 

The  cystoscope  is  often  exceedingly  useful  in  detecting  papillomata. 
The  manner  of  using  the  instrument  is  described  in  the  Diagnosis  of 
Stone  in  the  Bladder. 

Trcatmoit. — The  i)rofuse  hemorrhage  and  painful  cystitis  which  fre- 
quently attend  vesical  tumors   render  it  imperative  that  the  growths 


Fig.  179. — Thompson's  vesical  forceps  for  removing  growths  in  the  bladder.  For  grov^'ths 
close  to  the  neck  of  the  bladder,  with  separation  of  blades  to  avoid  nipping  the  neck  of  the 
bladder. 

should  be  removed  at  an   early  period  when  this  is  possible.     The 
removal  can  be  effected  by  the  suprapubic  or  the  perineal  route. 

The  suprapubic  operation  gives  a  better  opportunity  of  examining 
and  dealing  with  the  growth,  and  is  applicable  to  almost  every  case. 
The  technique  of  the  operation  has  been  already  described  (see  Supra- 
pubic Lithotomy,  p.  403).  Having  opened  the  bladder,  the  edges  of 
the  wound  should  be  held  apart  with  retractors,  and  a  strong  light 
thrown  into  the  viscus  either  by  a  forehead  mirror  or  a  small  electric 
lamp.  Papillomatous  growths  can  sometimes  be  scraped  off  with  the 
finger-nail  or  with  a  sharp  curette.  If  the  growth  has  a  slender  ped- 
icle, it  can  be  twisted  off  with  one  or  other  of  the  forceps  devised  by 


THE    GENITO-URINARY  SYSTEM.  407 

Sir  Henry  Thompson  (Fig.  179).  Stout  pedicles  should  be  grasped 
by  rectangular  forceps  close  to  the  bladder-wall  and  firmly  held,  while 
a  second  pair  of  forceps  grasps  the  pedicle  close  to  the  instrument  and 
twists  off  the  growth.  The  ecraseur  has  been  used  to  good  advantage, 
and  it  may  be  necessary  at  times  to  transfix  the  growth  with  a  needle 
of  suitable  shape  on  a  handle  and  tie  off  the  pedicle  with  a  double 
ligature.  When  all  the  growths  are  removed  the  surface  of  the  blad- 
der is  wiped  off  with  soft  sea-sponges  to  remove  all  blood-clots  and 
particles  of  tumor.  The  after-treatment  is  the  same  as  for  suprapubic 
cystotomy  as  employed  for  the  removal  of  stone. 

Perineal  cystotomy  is  advocated  by  many  surgeons  on  account  of 
the  drainage  facilities  which  can  be  secured  by  its  employment.  It, 
however,  does  not  give  free  access  to  more  than  the  neck  of  the  blad- 
der, is  wholly  inapplicable  in  cases  complicated  with  enlarged  prostate, 
and  never  admits  of  the  full  and  direct  examination  of  the  interior  of 
the  bladder  which  can  be  obtained  by  the  suprapubic  operation.  When 
it  is  resorted  to  the  median  incision  is  the  one  adopted. 

When  the  tumor  involves  the  bladder-wall  a  section  of  its  entire 
thickness  has  been  removed.  Sonneberg  excised  the  upper  two-thirds 
of  the  bladder,  including  the  peritoneum  w^hich  covered  it,  and  closed 
the  wound  with  sutures.  The  patient  died  at  the  end  of  six  weeks, 
Antal  was  more  successful.  In  his  case  the  tumor  was  about  the  size 
of  a  child's  fist.  He  removed  the  growth  and  the  portion  of  the 
bladder-wall  from  which  it  sprang.  The  patient  survived,  and  was 
able  to  retain  his  urine  for  three  or  four  hours.  The  incision  was 
suprapubic,  and  the  peritoneum  was  stripped  up  without  being  opened. 

Deformities  of  the  Bladder. — Absence  of  the  bladder  is  a  rare 
congenital  deformity.  In  the  cases  which  have  been  reported  the 
ureters  opened  directly  into  the  urethra  without  the  intervention  of  a 
separate  receptacle  for  the  urine,  into  the  vagina,  into  the  rectum,  or 
externally  near  the  umbilicus.  The  subjects  of  this  deformity  generally 
have  other  defects,  as  imperforate  anus,  undescended  testicle,  etc. 

There  is  no  treatment  worthy  of  mention,  as  all  the  attempts  which 
have  so  far  been  made  to  construct  a  new  bladder  have  proved 
unavailing. 

Double  or  multiple  bladder  has  occasionally  been  met  with.  The 
double  bladders  reported  were  produced  by  a  septum  which  divided  the 
viscus  into  two  compartments.  One  of  these,  reported  by  Dr.  Smith 
of  Baltimore,  is  remarkable.  The  patient  sought  advice  for  fre- 
quent micturition,  and  on  examination  was  found  to  have  a  double 
penis  and  a  bladder  divided  into  two  compartments  by  a  septum.  One 
of  these  contained  a  stone,  the  removal  of  which  cured  his  disease. 

Extroversion  or  exstropJiy  of  the  bladder  is  one  of  the  most  distress- 
ing and  loathsome  conditions  to  which  a  human  being  can  be  subject. 
It  is  a  failure  of  union  of  the  sides  of  the  uro-genital  cleft,  resulting  in 
absence  of  the  anterior  wall  of  the  bladder,  a  portion  of  the  abdominal 
wall,  and  the  symphysis  pubis.  Through  the  opening  thus  formed  the 
bladder  protrudes  as  a  fungating  mass  covered  with  an  unhealthy 
tenacious  mucus,  and  discharging  ammoniacal  urine  which  irritates  and 
excoriates  the  neighboring  parts.  The  penis  and  prostate  are  usually 
rudimentary,  and  there  is  often  a  double  inguinal  hernia. 


4o8 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


Treatment. — Of  mechanical  appliances  designed  to  collect  the  urine 
in  this  distressing  complaint,  the  best  is  that  manufactured  by  Tiemann 
&  Co.  of  New  York,  consisting  of  a  metallic  or  hard-rubber  shield 
which  is  applied  over  the  exstrophied  bladder.  From  the  lower  part  of 
the  shield  a  soft-rubber  tube  carries  the  urine  to  a  rubber  bag  buckled 
to  the  thigh. 

Operative  procedures  have  not  been  very  satisfactory.  Wood's  ope- 
ration consists  in  turning  down  a  flap  from  the  abdomen  between  the 
opening  and  the  umbilicus ;  two  other  flaps  are  taken,  one  from  the 
groin  on  either  side,  and  superimposed  upon  the  first  flap  (Fig.   i8o). 


Fig.  i8o. — Wood's  operation  for  exstrophy  of  the  bladder  (Ashhurstj. 

A  represents  the  first  flap  dissected  from  the  abdomen  and  turned 
down.  B  and  C  represent  the  lateral  flaps,  which  are  united  in  the 
middle  line  by  their  bases  a,  b  and  a' ,  b' .  This  operation  is  best  suited 
to  the  female  bladder,  while  the  operation  of  Maury  is  adapted  to 
exstrophy  in  males.  It  is  performed  as  follows :  A  curvilinear  in- 
cision is  carried  from  the  outer  third  of  Poupart's  ligament  across  the 
middle  of  the  perineum  to  the  corresponding  point  on  the  opposite  side. 
A  flap  from  the  perineum  and  scrotum  is  dissected  up  until  the  root  of 


THE    GENITO-URINARY  SYSTEM.  409 

the  penis  is  reached.  An  opening  is  then  made  in  the  center  of  the  flap 
and  the  penis  is  pushed  through  it.  A  second  flap  is  obtained  by 
carrying  a  curvihnear  incision  across  the  abdomen.  This  flap  is  about 
an  inch  in  length.  The  cutaneous  surface  is  first  vivified,  and  then 
pushed  under  the  abdominal  flap  and  secured  by  stitches. 

So  unsatisfactory  have  all  plastic  operations  proved  that  Harrison 
concludes  the  best  results  will  be  obtained  eventually  in  the  following 
way  :  "  By  (i)  the  establishment  of  a  lumbar  fistula  with  one  kidney, 
preferably  the  right  one,  and  (2)  the  removal  of  the  opposite  kidney  as 
soon  as  the  urinary  fistula  has  been  rendered  permanent.  In  this  way 
the  whole  of  the  urine  would  be  voided  through  one  fistula,  means 
being  taken  to  collect  the  excretion  as  it  escapes." 

Cystocele  and  Hernia  of  the  Bladder. — Repeated  over-disten- 
tion  of  the  bladder  and  weakness  of  the  abdominal  wall  sometimes 
result  in  the  formation  of  a  hernia  of  the  bladder.  The  viscus  may 
protrude  in  the  linea  alba,  or,  like  a  hernia  of  the  intestine,  it  may 
follow  the  course  of  the  cord  or  great  vessels  and  appear  at  the  ingui- 
nal or  the  femoral  ring.  In  females  the  most  common  situation  for 
cystocele  is  the  vagina,  the  bladder  protruding  between  the  labia. 

Symptoms. — The  hernial  tumor  presenting  at  any  of  the  openings 
mentioned  is  soft  and  fluctuating ;  it  enlarges  gradually  as  the  bladder 
fills  with  urine,  and  suddenly  diminishes  with  every  act  of  micturition. 
In  cases  of  doubt  a  small  aspirating  needle  may  be  used  to  draw  off 
the  contents  of  the  tumor. 

Treatment. — When  the  hernia  is  reducible  a  truss  can  be  worn  with 
great  advantage.  For  irreducible  cystoceles  a  truss  with  a  concave  pad 
will  prevent  increase  of  the  tumor.  Vaginal  cystocele  is  often  greatly 
improved  by  a  plastic  operation,  but  in  the  other  varieties  operative 
measures  have  given  no  satisfaction. 

IV.  INJURIES   AND   DISEASES  OF  THE  PROSTATE. 

Surgical  Anatomy. — The  prostate  {zpoovarr^z,  standing  before)  is 
a  body  partaking  of  the  nature  of  both  a  muscle  and  a  gland.  It 
owes  its  name  to  the  fact  that  it  stands  before  the  bladder,  being  placed 
at  the  outlet  of  that  viscus  and  surrounding  its  neck.  The  first  inch 
of  the  urethra,  measuring  from  the  bladder,  passes  through  the  pros- 
tate. The  average  length  of  the  prostatic  urethra  in  adults  is  an  inch 
and  a  quarter.  It  is  situated  behind  the  triangular  ligament,  and  can 
be  distinctly  felt  by  digital  examination  of  the  rectum.  The  size  of  the 
prostate  is  about  that  of  a  horse-chestnut,  or  an  inch  and  a  half  in 
breadth,  three-quarters  of  an  inch  in  thickness,  and  an  inch  antero- 
posteriorly.  Much  discussion  has  taken  place  as  to  whether  the  pros- 
tate is  a  muscle  or  a  gland.  It  is  both.  Unstriped  muscular  fibers 
compose  the  bulk  of  its  structure,  and  the  action  of  these  muscular 
fibers  is  to  contract  at  the  beginning  of  the  sexual  orgasm,  and,  as 
soon  as  the  semen  has  distended  the  prostatic  sinus,  to  force  it  out  in 
successive  jets  or  spurts.  It  also  contains  some  glandular  tissue,  which 
is  composed  of  a  number  of  follicles  hned  with  columnar  epithehum, 
and  which  empty  by  fifteen  or  twenty  excretory  ducts  into  the  floor  of 
the  prostatic  portion  of  the  urethra.     These  openings  are  marked  by  a 


4IO  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

depression  on  cither  side  of  the  floor  of  the  urethra  (the  prostatic  sinus), 
while  between  the  two  is  a  ridge  of  highly  erectile  tissue,  the  vcru- 
montanum,  supposed  to  be  the  principal  seat  of  sexual  sensibility. 
The  prostate  is  divided  into  two  lateral  lobes  by  a  furrow  on  the 
upper  and  lower  surfaces  and  by  a  deep  notch  behind.  When  a 
third  or  middle  lobe  is  spoken  of,  it  is  pathological,  being  due  to 
hypertrophy  of  the  portion  which  lies  between  the  two  lateral  lobes. 
It  is  hekf  in  position  by  the  posterior  layer  of  the  triangular  ligament, 
the  pubo-prostatic  ligament,  and  the  deep  perineal  fascia.  Its  vascular 
supply  is  abundant  and  derived  from  the  internal  pudic,  vesical,  and 
hemorrhoidal  arteries.  The  veins  form  a  plexus  about  the  organ,  and 
freely  inosculate  with  those  which  carry  the  blood  from  the  rectum  and 
anus.  A  study  of  the  prostatic  urethra  is  important  from  a  diagnostic 
standpoint.  In  children  it  has  a  sharp  curve  and  is  quite  short,  increas- 
ing in  length  as  years  advance,  so  that  in  adult  life  its  average  length 
is  one  inch  and  a  quarter.  The  length  and  direction  of  the  curve  are 
subject  to  important  modifications  by  disease. 

The  prostate  bears  a  close  resemblance  to  the  uterus  in  anatomical 
structure  and  physiological  character.  This  is  important  to  remember, 
and  its  significance  will  be  apparent  in  the  diagnosis  and  treatment  of 
the  diseases  which  we  shall  presently  consider. 

General  Symptoms  of  Prostatic  Disease. — As  in  the  case  of 
the  bladder,  our  attention  is  directed  to  the  prostate  by  three  guiding 
symptoms — viz.  pain,  frequency  of  micturition,  and  hematuria. 

Paul  in  prostatic  disease  is  felt  in  the  rectum  and  perineum.  In 
cases  of  commencing  prostatitis  the  pain  may  be  felt  simultaneously  in 
the  rectum,  perineum,  and  urethra.  It  is  felt  during  the  act  of  micturi- 
tion, for  the  distention  of  the  urethra  as  the  urine  flows  through  it  and 
the  contraction  of  the  bladder-wall  in  the  act  of  expulsion  cause  pres- 
sure upon  the  inflamed  prostatic  tissue.  For  similar  reasons  pain  is  felt 
during  defecation. 

Frequency  of  micturition  is  usually  most  troublesome  at  night  and 
while  the  patient  is  at  rest.  The  urine,  instead  of  coming  away  in  a 
stream  of  considerable  force,  drops  directly  to  the  ground  and  the 
bladder  contains  more  or  less  residual  urine. 

Hematuria. — The  blood  is  discharged  in  clots,  sometimes  of  con- 
siderable length,  having  been  moulded  in  the  urethra,  and  they  are 
expelled  before  the  urine. 

Attracted  by  one  or  more  of  the  symptoms  just  named,  a  systematic 
examination  of  the  prostate  should  be  made  for  the  following  diseases 
and  injuries  :  Jiypo'trophy,  prostatitis,  calculi,  malignant  disease,  ivoiinds, 
and  contusio)is. 

Hypertrophy  is  the  most  common  of  all  the  affections  of  the  pros- 
tate. After  middle  life  the  prostate  has  a  natural  tendency  to  enlarge- 
ment, and  in  about  lo  per  cent,  of  men  over  fifty-five  years  of  age  this 
enlargement  is  sufficient  to  cause  inconvenience.  The  causes  assigned 
for  hypertrophy  are  almost  as  numerous  as  the  writers  on  the  subject ; 
an  enumeration  of  them  would  be  of  no  practical  value.  It  cannot  well 
be  denied  that  excessive  functional  activity  is  a  predisposing  cause,  just 
as  frequent  childbearing  leads  to  analogous  changes  in  the  uterus. 

The  prostate  is  generally  enlarged  in  every  direction,  but  it  is  not 


THE    GENITO- URINAR Y  SYS TEM. 


411 


uncommon  to  find  local  hypertrophy  in  the  form  of  separate  tumors 
like  uterine  fibro-myomata.  The  increase  takes  place  in  the  muscular 
and  fibrous  elements,  the  glandular  structure  remaining,  as  a  rule, 
unchanged.  A  general  uniform  enlargement  may  produce  very  little 
trouble^  from  the  fact  that  the  urethra  is  slightly  if  at  all  interfered  with, 
while  a  localized  hypertrophy  or  tumor,  even  if  small,  may  change  the 
course  of  the  urethra  and  produce  serious  obstruction.  The  most 
common  position  for  enlargement  to  begin  is  in  the  middle  line  pos- 
teriorly, giving  rise  to  the  so-called  middle  lobe.  It  can  readily  be 
understood  that  a  small  amount  of  hypertrophy  in  this  situation  can 
change  the  shape  of  the  urethra  (Fig.  181).  The  lateral  lobes  also  are 
frequently  enlarged,  and  by  their  encroachment  upon  the  urethra  that 
canal  may  be  converted  into  a  narrow  slit  or  be  rendered  so  tortuous  as 
to  make  it  exceedingly  difficult  to  pass  an  instrument  through  it.  In 
such  cases  also  the  prostatic  portion  of  the  urethra  is  generally  in- 


FlG.  181. — Perpendicular  section  through  the  bladder,  median  enlargement  of  the  prostate 
and  prostatic  urethra:  a,  greatly  thickened  bladder-wall;  b,  left  lateral  lobe  of  prostate  ;  c, 
middle  prostatic  lobe;  </,  bas  fond  of  interior  of  bladder,  the  hypertrophied  middle  lobe  con- 
taining small  stone  (Watson). 

creased  in  length,  so  that  instead  of  being  an  inch  and  a  quarter  it 
may  measure  three  or  four  inches. 

Symptoms. — Two  conditions  are  responsible  for  nearly  all  the  symp- 
toms which  mark  the  course  of  prostatic  hypertrophy — viz.  obstruc- 
tion to  the  flow  of  urine  and  infection  of  the  bladder  with  pyogenic 
organisms.  Obstruction  is  generally  first  noticed  by  the  fact  that  the 
stream  is  diminished  in  force,  and  the  urethra  is  not  so  completely 
emptied  at  the  end  of  micturition  as  in  days  gone  by.  Frequency  of 
micturition  soon  follows,  and  the  characteristic  which  distinguishes  it 
from  the  same  symptoms  due  to  other  causes  is  that  it  is  worse  while 
the  patient  is  in  bed.  He  has  to  get  up  at  night,  and  this  goes  on  with 
increasing  frequency  until  it  becomes  a  great  annoyance.  At  the  same 
time,  the  bladder-wall  loses  its   tone,  and  is  unable  to  expel  the  urine 


412  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

with  wonted  force ;  the  stream  is  sluggish,  and  may  fall  directly  to 
the  ground,  scarcely  clearing  the  patient's  feet.  In  spite  of  the  loss 
of  force,  the  stream  maintains  its  full  size,  thus  distinguishing  en- 
larged prostate  from  stricture  of  the  urethra.  The  time  comes  when 
the  bladder  fails  to  empty  itself,  and  if  immediately  after  urination 
a  catheter  be  passed,  several  ounces  of  "  residual  "  urine  can  be  with- 
drawn. 

The  observance  of  these  symptoms  naturally  leads  us  to  make  a 
local  examination  of  the  prostate  itself,  and  this  can  be  done  very  satis- 
factoril)'  by  a  digital  examination  in  the  rectum.  The  patient  is  placed 
on  his  back  witli  the  knees  drawn  up  and  separated  to  an  extent  that 
gives  perfect  relaxation.  The  bowel  should  be  emptied  by  an  enema ; 
and  in  sensitive  patients  a  suppository  of  morphin  or  cocain,  introduced 
half  an  hour  before  the  examination,  will  allay  irritability. 

The  examiner  having  filled  the  space  beneath  the  nail  with  hard  soap 
and  lubricated  the  finger,  passes  it  into  the  rectum  with  the  palmar  sur- 
face directed  forward.  At  a  distance  conveniently  within  reach  the 
prostate  can  be  felt  and  its  outline  clearly  distinguished.  The  degree 
of  projection  into  the  rectum,  the  size  of  the  lateral  lobes,  the  existence 
of  the  so-called  middle  lobe,  the  irregularities  of  surface,  and  the 
dimensions  of  the  whole  prostatic  body  should  be  carefully  considered. 
Having  completed  the  rectal  examination,  the  patient  should  be  required 
to  urinate,  and  then  a  catheter  is  passed  into  the  bladder.  This  will 
settle  the  question  of  residual  urine,  and,  if  need  be,  the  instrument 
may  be  used  in  combination  with  the  rectal  examination.  With  a 
metallic  catheter  on  one  side  of  the  prostate  and  the  finger  on  the 
other  the  surgeon  can  gain  very  accurate  knowledge  of  the  size  and 
shape  of  the  gland.  Valuable  information  can  be  obtained  from  the 
manner  in  which  the  catheter  passes  into  the  bladder.  If  it  goes  in 
without  the  handle  having  to  be  depressed  to  any  great  extent,  and  the 
urine  flows  when  the  instrument  has  penetrated  to  a  depth  of  seven  or 
eight  inches,  there  is  no  prostatic  enlargement.  When  the  prostate  is 
enlarged  the  handle  of  the  catheter  has  to  be  depressed  well  down 
toward  the  patient's  feet  before  the  point  can  be  made  to  enter  the 
bladder,  and  the  instrument  may  have  to  be  pushed  in  to  a  depth 
of  ten  inches  before  the  urine  begins  to  flow.  This  is  why  long 
catheters  with  a  large  full  curve  have  been  made  expressly  for  prostatic 
enlargement. 

The  residual  urine  plays  an  important  part  in  the  course  of  the 
disease  :  not  that  the  presence  of  urine  of  itself  causes  annoyance,  for 
normal  urine  sets  up  no  irritation  and  gives  no  trouble.  It  is  when  the 
fluid  becomes  infected  with  pyogenic  bacteria  that  trouble  begins. 
Cystitis  follows,  the  frequency  of  micturition  is  increased,  and  the 
patient,  unless  properly  treated,  endures  all  the  evils  which  attend 
chronic  inflammation  of  the  bladder.  Mucus  in  large  quantities  is 
voided  with  the  urine ;  gradually  the  fluid  loses  its  normal  acidity, 
becomes  alkaline,  ammoniacal,  and  foul-smelling.  Hematuria  comes, 
as  a  rule,  in  cases  of  long  standing  and  is  due  to  congestion  of  the 
affected  parts.  The  blood  is  expelled  before  the  urine,  and  is  in  the 
form  of  long  cylindrical  clots  which  have  been  moulded  by  the  urethra. 
Sometimes  the  flow  of  this  blood  from  the  engorged  tissues  is  followed 


THE    GENITO-URINARY  SYSTEM.  413 

by  a  sense  of  relief  and  a  temporary  improvement  in  the  general 
symptoms. 

The  effect  of  enlarged  prostate  upon  the  sexual  function  is  often 
marked,  leading  to  troublesome  priapism  and  to  abnormal  sexual  appe- 
tite, even  in  very  old  men.  The  opposite  result,  impotency,  is  some- 
times observed.  Incontinence  of  urine  at  night  is  a  distressing  symptom 
in  some  of  the  cases.  It  is  due  to  loss  of  tonicity  in  the  cut-off  muscle. 
During  waking  hours  the  patient  by  his  volition  can  compensate  for 
this  loss  of  tone  ;  in  sleep  volition  is  in  abeyance  and  the  urine  escapes. 

Retention  is  a  frequent  complication,  and  is  brought  about  by 
excessive  sexual  indulgence,  by  intemperate  eating  and  drinking,  and 
by  exposure  to  cold  and  wet. 

Calculus  is  apt  to  appear  as  one  of  the  most  distressing  of  all  com- 
plications. The  pain  is  not  so  severe,  however,  as  when  calculus  occurs 
under  other  circumstances.  It  is  most  marked  when  riding  in  a  jolting 
vehicle  or  on  horseback.  Sudden  stoppage  of  the  stream  during  mic- 
turition is  not  likely  to  occur,  for  the  stone  lies  in  a  depression  behind 
the  enlarged  prostate  and  is  not  forced  against  the  opening  of  the 
urethra. 

Diagnosis. — The  conditions  most  likely  to  lead  to  error  are  stricture 
and  calculus.  The  question  of  differential  diagnosis  should  never  be 
considered  without  a  rectal  examination,  for,  wanting  this,  the  examiner 
is  in  no  position  to  decide.  The  age  of  the  patient  has  an  important 
bearing :  enlarged  prostate  is  not  commonly  met  with  before  the  age 
of  fifty-five ;  stricture  is  an  affliction  of  young  men.  The  stream  of 
urine  in  prostatic  enlargement  is  slow  and  weak,  but  of  full  size,  while 
in  stricture  it  is  small  or  forked  or  a  mere  dribble.  The  size,  shape,  and 
contour  of  the  prostate  as  determined  by  digital  examination  are  the 
only  infallible  guides  to  a  correct  diagnosis.  Acute  prostatitis  is  recog- 
nized by  the  history  of  a  gonorrheal  infection,  by  heat  and  tenderness 
on  local  examination,  and  by  pain  in  defecation. 

Carcinoma  of  the  prostate  may  be  suspected  if  the  hematuria  is 
copious  and  the  enlargement  irregular  in  shape  and  of  uniform  con- 
sistence. 

Tuberculosis  of  the  prostate  is  generally  secondary  to  disease  in 
other  parts,  and  can  be  disposed  of  by  examination  of  the  urine  for 
tubercle  bacilli. 

Treatment. — The  treatment  of  prostatic  hypertrophy  has  until  recent 
years  been  merely  palliative.  It  is  a  fortunate  thing  that  two-thirds  of 
all  persons  with  enlarged  prostates  go  through  life  without  the  necessity 
of  treatment.  In  the  early  stages,  when  frequent  micturition  is  the  only 
symptom,  the  patient  is  not  likely  to  seek  surgical  aid,  and  when  exam- 
ined he  is  surprised  to  find  that  he  has  been  unable  to  expel  all  the 
urine  from  his  bladder.  The  amount  of  residual  urine  and  the  number 
of  times  the  patient  is  disturbed  at  night  must  guide  us  in  our  treat- 
ment. If  he  is  obliged  to  rise  only  once  or  twice  a  night,  if  the  urine  is 
normal,  and  the  residual  fluid  not  exceeding  an  ounce  or  two,  no  instru- 
mental treatment  is  required.  The  patient  should,  however,  strictly 
carry  out  the  following  general  treatment :  The  body  should  be  well 
clothed,  so  as  to  avoid  chilling  of  the  surface  ;  the  diet  should  be  light 
and  digestible ;  alcohol  and  malt  liquors  should  be  avoided :  the  bowels 


414  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

should  be  carefully  regulated ;  and  the  urine  should  be  voided  at  stated 
intervals.  When  the  patient  is  disturbed  three  or  four  times  a  night 
and  the  residual  urine  amounts  to  more  than  two  ounces,  and  especially 
if  it  be  ammoniacal  or  otherwise  unhealthy,  the  use  of  the  catheter  is 
indispensable.  The  instrument  should  be  soft  and  flexible.  It  should 
be  thoroughly  cleansed  inside  and  out  before  and  after  using,  and  should 
be  regularly  kept  in  a  weak  solution  of  carbolic  acid.  When  the  residual 
urine  is  normal  in  character,  although  amounting  to  several  ounces,  it 
may  be  sufficient  to  use  the  catheter  each  night  at  bedtime.  With  ammo- 
niacal urine  and  marked  atony  of  the  bladder  two,  three,  or  four  passages 
of  the  instrument  each  day  may  be  necessary.  Too  great  care  cannot 
be  observed  in  getting  the  urethra  and  bladder  accustomed  to  the 
passage  of  a  catheter.  The  first  attempt  should  be  made  while  the  pa- 
tient is  warm  in  bed,  and  he  should  remain  there  for  twenty-four  hours 
afterward,  and  keep  his  room  for  several  days  longer.  When  the  use 
of  the  instrument  has  been  continued  for  several  weeks  the  patient 
can  be  taught  to  catheterize  himself  Some  men  have  treated  them- 
selves in  this  way  for  thirty  years  and  passed  their  days  in  comparative 
comfort. 

Besides  the  use  of  the  catheter,  the  other  means  worthy  of  attention 
are  the  following : 

{a)  Massage  of  the  prostate.  This  is  carried  out  by  the  finger  in  the 
rectum,  gently  stroking  the  gland  in  the  direction  of  the  anus,  con- 
tinued for  five  minutes  and  repeated  once  a  week.  The  vesiculae 
seminales  are  in  this  way  emptied. 

ib)  Bladder-gymnastics.  Water  at  a  temperature  of  ioo°  to  iio°  F. 
is  injected  into  the  meatus,  and  thence  flows  into  the  bladder  by  over- 
coming the  weakened  sphincter.  The  patient  lies  on  his  back  with  the 
head  and  shoulders  well  raised  and  the  knees  drawn  up.  When  the 
bladder  becomes  moderately  distended,  it  is  allowed  to  empty  itself,  and 
on  this,  I  presume,  is  based  the  unhappy  term  "  bladder-gymnastics." 
The  chief  benefit  of  the  method  lies  in  the  hot  water,  which  reduces 
the  edema  and  congestion  of  the  mucous  membrane  and  gives  tone  to 
the  muscular  structure  of  the  bladder. 

if)  Injections  for  the  relief  of  cystitis.  As  already  stated,  the  best 
of  these  is  a  solution  of  silver  nitrate.  Large  quantities  of  a  weak 
solution  (gr.  \  to  sj)  can  be  employed,  or  a  stronger  solution  can  be 
thrown  into  the  bladder  and  immediately  washed  out  with  sterilized 
water. 

In  very  obstinate  cases  in  which  the  catheter  fails  to  afford  relief 
drainage  of  the  bladder  is  indicated.  The  simplest  operation  for  this 
purpose  is  that  recommended  by  Harrison  :  A  straight  trocar  is  pushed 
through  the  perineum  in  the  middle  line  and  one  inch  in  front  of  the 
anus.  Guided  by  the  index  finger  in  the  rectum,  the  instrument  is  made 
to  enter  the  bladder  ;  the  trocar  is  then  withdrawn  and  a  self-retaining 
catheter  put  in  its  place ;  after  which  the  cannula  is  removed.  Through 
the  catheter  irrigating  fluids  may  be  injected  from  time  to  time.  Other 
methods  of  draining  the  bladder  are  the  median  incision,  as  for  lith- 
otomy, and  the  suprapubic  incision.  The  latter  has  the  advantage  of 
allowing  more  thorough  exploration  of  the  bladder  and  prostate,  and, 
if  necessary,  the  employment  of  more  radical  measures. 


THE    GENITO-URINARY  SYSTEM. 


415 


The  operativ^e  procedures  designed  to  permanently  relieve  the  symp- 
toms resulting  from  enlarged  prostate  are — 

1.  Double  Castration. — This  operation  has  not  advanced  beyond  the 
experimental  stage,  and  yet  the  number  of  successful  cases  which 
have  been  reported  is  very  encouraging.  After  numerous  experiments 
on  animals,  White  suggested  the  operation  as  likely  to  be  followed  by 
atrophy  of  the  prostate.  Ramm  of  Christiania  also  experimented  on 
animals,  and  tested  his  theories  by  successfully  operating  on  two  old 
men.  Over  100  cases  have  been  reported,  and  as  a  rule  the  results 
have  been  satisfactory.  The  operation  is  safer  than  prostatectomy,  it 
can  be  performed  much  more  rapidly,  and  the  patient  is  kept  under 
anesthesia  a  much  shorter  time. 

2.  Ligation  of  both  vasa  dcfcrcntia  has  been  tried  in  a  few  cases,  and 
promises  results  as  good  as  those  obtained  by  castration. 

3.  Prostatectomy. — In  dealing  with  the  enlargement  of  the  prostate 
which  gives  rise  to  serious  bladder-symptoms  McGill  makes  the  follow- 


FlG.    182. — Jessop's  prostate-scissors. 

ing  classifications:  i,  a  projection  of  the  middle  lobe,  pedunculated  or 
sessile  ;  2,  an  hypertrophy  of  the  middle  lobe  and  the  two  lateral  lobes, 
making  three  distinct  intra-vesical  projections;  3,  enlargements  of  the 
lateral  lobes  only  ;  4.  a  uniform  collar-like  projection  encircling  the 
orifice  of  the  urethra. 

It  is  for  the  removal  of  one  or  other  of  these  intra-vesical  growths 
that  prostatectomy  is  undertaken.  The  prostate  can  be  approached  by 
the  suprapubic  or  the  perineal  route. 

{a)  Suprapubic  Prostatectomy. — McGill's  Operation. — The  technique 
of  opening  the  bladder  is  exactly  as  described  under  Suprapubic  Lith- 
otomy. The  edges  of  the  incision  in  the  bladder  are  sutured  to  the 
abdominal  wall  by  a  stitch  at  each  side  and  at  the  lower  angle  of  the 
wound.  The  bladder  is  then  explored  for  the  projecting  growth. 
When  possible,  enucleation  with  the  finger,  after  first  dividing  the 
mucous  membrane  over  the  projection,  is  the  safest  manner  of  removal. 
A  pedunculated  middle  lobe  can  be  removed  with  curved  scissors,  or  if 


41 6  SURGICAL  DIAGNOSIS  AND    TREAI'MENT. 

sessile  it  may  be  twisted  off  with  forceps.  Jessop  of  Leeds  (Eng.)  has 
invented  an  instrument  (Fig.  182)  for  cutting  away  the  projecting  pros- 
tate either  at  once  or  piecemeal.  If  the  orifice  of  the  urethra  is  sur- 
rounded by  a  collar-like  growth,  this  should  be  divided  above  and 
below  and  then  enucleated  with  the  finger  or  scissors.  Hemorrhage  is 
sometimes  profuse,  but  can  be  controlled  by  irrigations  with  hot  water. 
After  the  operation  the  large  drainage-tube  is  left  in  the  bladder  for 
forty-eight  hours,  the  wound  above  and  below  the  tube  being  united 
by  deep  and  superficial  sutures.  The  bladder  should  be  kept  aseptic 
by  irrigations  of  boric-acid  solution. 

Nicoll  of  Glasgow,  after  opening  the  bladder  in  the  manner  just 
described,  makes  a  median  perineal  incision  down  to  and  through  the 
prostatic  capsule  without  cutting  into  the  urethra  or  neck  of  the  blad- 
der. With  one  hand  in  the  suprapubic  wound  the  prostatic  growth  can 
be  pressed  down  and  steadied  within  reach  of  the  fore  finger  of  the 
other  hand  in  the  perineal  incision.  The  perineal  finger  then  shells  out 
the  growth. 

{b)  Perineal  Prostatectojiiy. — The  objection  to  this  operation  is  the 
difficulty  of  reaching  the  prostatic  enlargement  with  the  finger  and  the 
small  space  available  for  manipulation.  The  median  incision  is  the  one 
which  has  generally  been  adopted. 

(r)  Lateral  prostateetoviy  (Dittel's  operation)  has  no  advantage 
worthy  of  recommendation.  A  catheter  is  tied  in  the  bladder,  and  the 
rectum  filled  with  gauze  for  the  purpose  of  enabling  the  surgeon  to 
recognize  and  avoid  these  structures.  The  patient  lies  on  his  belly  and 
his  legs  hang  down  over  the  end  of  the  table.  Beginning  at  the  tip 
of  the  coccyx,  an  incision  is  carried  to  the  right  around  the  sphincter 
ani  to  the  middle  line  in  front.  This  lays  open  the  ischio-rectal  fossa ; 
the  rectum  is  held  aside  and  one  lobe  of  the  prostate  is  exposed.  Dis- 
section on  the  other  side  of  the  middle  line  exposes  the  other  lobe,  and 
a  wedge-shaped  portion  is  removed  from  each. 

All  prostatectomies  are  unsatisfactory,  and  in  the  search  for  remedial 
aid  perhaps  nothing  has  been  devised  that  is  better  than  an  artificial 
urethra.  By  the  suprapubic  operation,  which  is  acknowledged  to  be  the 
best,  the  mortality  following  prostatectomy  is  from  16  to  20  per  cent. 
This  is  not  to  be  wondered  at  when  we  consider  that  the  patients  are 
mostly  old  and  enfeebled  with  suffering,  their  disease  complicated  with 
chronic  cystitis,  pyelo-nephritis,  atony  of  the  bladder,  and  not  infre- 
quently calculus.  The  formation  of  an  artificial  urethra  was  first 
devised  by  Harrison  in  1884,  ^"^^^  has  been  followed  by  happy  results 
in  the  hands  of  many  operators,  notably  Hunter  McGuire  in  America 
and  Poncet  in  France. 

Instead  of  the  perineal  incision  as  first  proposed  by  Harrison,  a 
suprapubic  urethra  is  now  generally  considered  the  best.  The  ope- 
ration as  practised  by  Hunter  McGuire  is  as  follows :  The  rectum 
is  distended  by  a  rectal  bag  or  by  sponges  or  cotton  in  order 
to  press  the  bladder  upward  and  forward  and  fix  it  against  the  ante- 
rior abdominal  wall.  Five  or  six  ounces  of  water  are  then  injected 
through  a  soft-rubber  catheter.  The  opening  into  the  bladder  is  the 
same  as  for  suprapubic  lithotomy.  The  bladder  is  then  examined,  first 
by  the  finger  and  then  with  a  small  electric  light  introduced  through 


THE    GENITO-URINARY  SYSTEM.  417 

the  suprapubic  wound,  or  an  assistant  with  two  fingers  in  the  rectum 
may  push  the  posterior  wall  of  the  bladder  up  toward  the  wound  and 
thus  facilitate  its  inspection.  A  large  catheter  is  now  introduced, 
and,  as  the  rectal  bag  is  allowed  to  drain  away,  the  point  of  the 
catheter  is  made  to  follow  the  bladder  as  it  sinks  lower  in  the  pel- 
vis ;  otherwise  it  might  slip  out  of  the  vesical  incision.  By  the  time 
the  rectal  bag  is  emptied  the  opening  in  the  bladder  will  be  found  to  be 
two  and  a  half  or  three  inches  lower  than  the  center  of  the  abdominal 
incision.  No  stitches  are  employed,  the  wound  being  allowed  to  heal 
around  the  catheter,  so  that  nothing  is  left  but  a  fistulous  tract  about 
three  inches  in  length  communicating  with  the  bladder  at  about  the 
angle  at  which  a  spout  is  fixed  to  a  coffee-pot.  The  patient  is  generally 
able  to  hold  and  expel  his  urine  at  will,  and  sometimes  the  stream  can 
be  forced  as  much  as  a  yard  from  his  body.  When  this  expulsive 
force  is  lacking  a  small  glass  funnel  can  be  fitted  over  the  suprapubic 
opening  during  the  act  of  micturition,  as  recommended  by  Dr.  Lydston. 

To  prevent  closure  of  the  artificial  opening,  it  is  necessary  to  wear  a. 
plug  which  can  be  made  of  silver  or  aluminum.  It  is  from  two  and  a. 
half  to  three  and  a  half  inches  in  length,  and  is  kept  in  position  by 
straps  fastened  around  the  hips.  It  is  removed  during  micturitiori 
and  afterward  replaced. 

Inflammation  of  the  Prostate  (Prostatitis). — Prostatitis  may 
be  confined  to  certain  portions  of  the  mucous  membrane  and  the  fol- 
licles connected  with  it,  producing  local  inflammations  and  leading  to 
abscesses  which  are  generally  small  and  rupture  into  the  urethra. 
This  variety  is  known  as  follicular  prostatitis.  Parcncliyinatoiis  pros- 
tatitis is  the  name  applied  to  an  inflammation  of  the  whole  prostatic 
body  ;  when  suppuration  takes  place  in  this  variety  the  pus  burrows 
into  the  surrounding  tissues  and  points  in  the  perineum  or  the  groin. 

Follicular  prostatitis  is  of  two  kinds — acute  and  chronic.  The 
acute  form  is  almost  invariably  connected  with  gonorrhea.  Rarely,  it 
is  due  to  injury,  either  traumatic  or  the  result  of  surgical  procedures,  to 
stricture,  or  to  the  use  of  caustics. 

Symptoms. — If  during  the  acute  stage  of  gonorrhea,  or  when  in  the 
later  stages  instruments  are  passed  into  the  urethra,  the  patient  is  seized 
with  pain  in  the  perineum,  with  or  without  a  chill,  the  likelihood  is  that 
acute  prostatitis  is  setting  in.  The  pain  is  of  an  intense  burning  cha- 
racter and  felt  at  the  neck  of  the  bladder.  Micturition  is  painful  and 
the  desire  is  constant.  Defecation  also  causes  pressure  on  the  prostatic 
body  and  is  attended  with  suffering.  The  perineum  throbs  and  the 
pain  runs  down  the  loins  and  thighs.  Sometimes  there  is  a  chill,  and 
there  is  always  more  or  less  fever,  as  indicated  by  the  temperature  and 
pulse.  All  of  these  symptoms  are  very  characteristic,  and  they  are 
fully  corroborated  by  a  digital  examination  through  the  rectum.  The 
prostate  is  hot,  swollen,  throbbing,  and  intensely  painful  to  touch. 

Chronic  follicular  prostatitis  may  be  a  continuation  of  the  acute 
form,  or  it  may  be  milder  and  run  a  course  of  less  intensity  from  the 
first.  The  only  difference  in  the  symptoms  is  that  they  have  not  the 
intensity  of  the  acute  form.  Instead  of  the  violent  throbbing  pain, 
there  is  a  dull  aching  in  the  perineum  extending  down  the  thighs  and 
across  the  loins.     The  passage  of  urine  or  feces  adds  greatly  to  this 


41 8  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

discomfort  by  pressure  upon  the  inflamed  structure.  Urination  is 
attended  with  scalding,  and  toward  the  end  it  is  not  uncommon  to 
find  a  few  drops  of  blood.  Rectal  examination  reveals  an  enlarged 
and  tender  prostate,  without  the  heat  and  throbbing  of  the  acute 
varict)'. 

Treatment. — In  acute  follicular  prostatitis  the  patient  should  keep 
his  bed  and  live  upon  light  diet.  The  bowels  should  be  evacuated 
once,  and  then  kept  quiet  for  several  days.  Hot-water  enemata  or 
half  a  pint  of  hot  water  containing  a  dram  of  laudanum  will  give  great 
relief  Fomentations  to  the  perineum  and  hip-baths  as  hot  as  can  be 
borne  are  also  useful.  Retention  of  urine  will  necessitate  the  use  of  a 
soft-rubber  catheter.  When  suppuration  occurs  in  the  perineum  free 
incisions  are  indicated.  The  rule,  however,  is  that  the  abscess  bursts 
into  the  urethra,  and  this  takes  place  probably  during  the  passage  of 
the  catheter.  A  free  flow  of  pus  with  the  urine  is  followed  by  a  sen- 
sation of  great  relief,  and,  as  the  tension  around  the  abscess  is  con- 
siderable, the  cavity  is  soon  emptied.  Chronic  prostatitis  is  difficult  to 
manage  and  obstinately  resists  all  treatment.  Tonics  and  the  best 
hygienic  conditions  are  indispensable ;  over-exertion  must  be  avoided, 
and  the  bowels  should  be  kept  relaxed  to  prevent  straining  at  stool.  In 
the  majority  of  cases  of  chronic  prostatitis  there  is  either  primarily  or 
secondarily  infectious  inflammation  of  the  prostatic  portion  of  the  ure- 
thra and  the  glands  and  ducts  connected  with  it ;  hence  antiseptic 
treatment,  both  local  and  general,  is  indicated.  The  internal  remedies 
are  those  that  disinfect  the  urine,  such  as  quinin,  the  various  balsams, 
and  eucalyptus.  Urethral  injections  carried  to  the  affected  part  are 
often  valuable  :  they  may  consist  of  nitrate  of  silver,  solution  of  tannic 
acid,  permanganate  of  potash,  or  bichlorid  of  mercury.  When  there 
are  collections  of  pus  about  the  perineum,  these  should  be  evacuated 
and  drained. 

Parenchymatous  Prostatitis. — The  causes  of  this  form  of  disease 
are  traumatism,  gout,  tuberculosis,  and  possibly  syphilis.  Clinically, 
we  may  set  down  all  cases  connected  with  gonorrhea  as  follicular,  and 
all  other  forms  of  prostatitis  as  parenchymatous.  The  whole  substance 
of  the  prostate  is  involved,  and  in  many  cases  profuse  and  long-con- 
tinued suppuration  causes  destruction  of  the  tissue.  Operations  for 
stone,  the  use  of  large  instruments  while  the  bladder  is  in  an  unhealthy 
condition,  and  chronic  kidney  disease  are  responsible  for  a  large  pro- 
portion of  the  cases  of  parenchymatous  prostatitis.  Frequently  the 
disease  is  ushered  in  with  a  chill  and  deep-seated  pain  in  the  perineum. 
The  enlargement,  heat,  and  tenderness  are  found  on  rectal  examination 
as  in  the  follicular  variety.  Suppuration  is  apt  to  follow,  and  the  pus 
may  burrow  into  the  recto-vesical  fascia,  and  thence  to  the  pelvis,  or  it 
may  form  an  abscess  in  the  perineum.  . 

Treatment. — As  soon  as  it  is  evident  that  suppuration  is  about  to 
take  place  or  has  already  begun,  an  incision  in  the  middle  line  down  to 
and  through  the  capsule  should  be  made  without  delay.  The  general 
treatment  is  the  same  as  for  the  preceding  forms. 

Gouty  prostatitis  is  found  in  persons  who  have  other  manifestations 
of  the  gouty  diathesis.  The  disease  is  congestive  and  irritable  rather 
than  inflammatory,  and  rarely  does  it  end  in  suppuration.     The  symp- 


THE    GENITO-URINARY  SYSTEM.  419 

toms  are  the  same  as  those  already  mentioned,  with  a  greater  tendency 
to  bladder-comphcations. 

The  tvcatnioit  is  that  of  gout  in  general. 

Tubercular  Prostatitis. — This  is  nearly  always  secondary  to  tuber- 
culosis in  other  parts,  especially  those  contiguous  to  the  prostate,  as 
the  testicles  and  bladder.  In  some  cases  it  occurs  as  a  primary  disease, 
the  bacilli  being  engrafted  upon  an  inflammatory  condition  of  the 
prostatic  urethra. 

Syniptouis. — Tubercular  prostatitis  closely  resembles  the  symptoms 
of  stone  in  the  bladder.  If  we  fail  to  find  a  stone,  and  find  more  or  less 
marked  evidence  of  prostatic  inflammation,  a  suspicion  of  tuberculosis 
may  be  entertained.  In  tubercular  prostatitis  the  patient  is  a  young  or 
middle-aged  man,  the  enlargement  as  felt  per  rectum  is  nodular,  the 
epididymes  are  enlarged,  and  the  bladder  is  inflamed.  To  corroborate 
this  diagnosis  the  detection  of  bacilli  in  the  urine  is  necessary.  This 
cannot  be  done  before  ulceration  has  taken  place.  When  there  is 
evidence  of  tuberculosis  in  the  lungs,  glands,  or  other  parts  of  the 
body,  the  diagnosis  can  be  made  positively. 

Treatment  is  not  very  satisfactory.  The  general  treatment  is  that 
of  tuberculosis  in  any  part  of  the  body.  Local  treatment  is  of  little 
value  except  when  the  disease  is  primary.  Abscesses  when  they  occur 
should  be  opened,  their  walls  curetted  and  packed  with  iodoform  gauze. 
Iodoform  emulsion  injected  into  the  prostatic  urethra  is  believed  to 
have  a  restraining  influence  on  the  growth  of  the  bacilli,  and  the  hypo- 
dermic use  of  iodin  and  chlorid  of  gold  in  the  form  of  Clark's  solution 
is  worthy  of  trial.  Under  any  circumstances  the  prognosis  of  tuber- 
cular prostatitis  is  highly  unfavorable  ;  when  it  is  secondary  to  tuber- 
culosis elsewhere,  the  patient's  chances  are  simply  nil. 

Malignant  Disease  of  the  Prostate. — Encephaloid  cancer  and 
sarcoma  are  the  two  forms  of  malignant  disease  found  in  the  prostate. 
The  two  extremes  of  life  furnish  nearly  all  the  cases.  Sarcoma  occurs 
in  children  below  ten  years  of  age  and  carcinoma  in  men  beyond  the 
age  of  fifty :  85  per  cent,  of  all  cases  are  carcinomatous. 

Diagnosis. — Very  naturally,  prostatic  hypertrophy  and  tuberculosis 
of  the  prostate  are  the  two  affections  which  are  likely  to  be  mistaken 
for  malignant  disease.  The  most  difficulty  in  making  a  diagnosis  is 
met  with  when  an  enlarged  prostate  becomes  the  seat  of  cancer. 
Besides  the  symptoms  which  arise  from  enlargement  of  the  prostate, 
pain,  especially  at  night  and  referred  to  the  rectum,  is  significant. 
Hemorrhage  is  often  profuse,  and  a  purulent  discharge  from  the  urethra 
is  common  when  there  is  ulceration.  The  rapidity  of  growth,  the 
extension  of  the  disease  to  the  rectum  and  pelvis,  the  involvement  of 
lymphatic  glands  in  Scarpa's  triangle,  and  the  development  of  a  can- 
cerous cachexia  leave  no  doubt  of  the  nature  of  this  terrible  disease 
when  once  it  has  become  fully  established. 

Treatment. — Radical  treatment  has  frequentiy  been  attempted,  but 
for  obvious  reasons  without  success.  The  palliative  measure  most 
likely  to  give  rest  to  the  affected  part  and  lessen  suffering  is  the 
formation  of  an  artificial  urethra  by  the  suprapubic  operation,  as  sug- 
gested by  Lydston. 

Calculus  of  the  Prostate. — Like  the  tonsil,  the  prostate  is  liable 


420  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

to  be  the  seat  of  calculi  composed  of  its  normal  secretions  which  have 
become  inspissated.  These  sometimes  occur  in  large  numbers,  which 
may  remain  each  in  a  separate  cavity,  or  they  may  finally  be  collected 
in  one  receptacle  by  the  breaking  down  of  the  septa  between  the 
cavities.  It  is  not  uncommon  for  a  vesical  calculus  to  become  arrested 
at  the  prostatic  portion  of  the  urethra,  and,  sinking  into  the  substance 
of  the  gland,  become  encysted,  a  portion  remaining  in  the  urethra. 

The  symptoms  of  prostatic  calculus  are  very  similar  to  those  of  stone 
in  the  bladder.  The  sound  may  be  found  to  strike  the  stone  before  the 
instrument  reaches  the  bladder ;  measurement  of  the  distance  from  the 
meatus  will  be  a  guide  to  the  part  of  the  urethra  involved.  Stone  in 
the  prostate  is  never  found  to  change  its  position  with  movement  of 
the  patient.  With  a  sound  in  the  bladder  and  a  finger  in  the  rectum 
the  examiner  may  be  able  to  locate  the  stone  in  the  prostate  between 
his  finger  and  the  instrument.  Numerous  small  calculi  can  sometimes 
be  felt  to  rub  against  each  other  when  the  finger  is  pressed  against  the 
prostate. 

Treatment. — If  the  stone  communicates  with  the  urethra,  a  large 
sound  may  push  it  back  into  the  bladder.  Small  calculi  may  be 
removed  with  forceps.  When  the  stone  is  firmly  encysted  a  median 
perineal  section  is  the  best  operation  for  its  removal. 

Wounds  and  Injuries  of  the  Prostate. — The  prostatic  body 
is  so  well  protected  by  the  pubic  and  ischiatic  bones  that  injury  is 
exceedingly  rare.  W^hen  injured,  therefore,  it  is  usually  a  complication 
of  a  severe  traumatism  of  the  pelvis  in  which  prostatic  injury  plays  but 
a  minor  part.  The  treatment  of  prostatic  wounds  must  be  carried  out 
on  general  principles,  the  most  important  point  to  keep  in  view  being 
the  avoidance  of  urinary  infiltration.  The  same  caution  applies  to 
wounds  of  the  gland  happening  in  the  course  of  operation. 

V.   INJURIES  AND   DISEASES  OF  THE  MALE   URETHRA. 

Surgical  Anatomy. — The  urethra  is  the  tube,  partly  muscular 
and  partly  membranous,  which  extends  from  the  bladder  to  the  meatus 
urinarius.  It  is  divided  into  three  portions,  as  follows  :  the  prostatic, 
the  membranous,  and  the  spongy,  penile,  or  pendulous.  Of  each  por- 
tion we  shall  give  a  brief  description. 

The  prostatic  portion  passes  through  the  prostate  body  nearer  to 
the  upper  than  to  its  lower  surface.  It  is  about  one  and  a  quarter 
inches  in  length,  and  is  the  most  dilatable  part  of  the  whole  urethra. 
Along  its  floor  extends  an  elevation,  broad  behind  and  narrow  in  front, 
called  the  verii  montajmin  or  collicnhcs  scviinalis.  Immediately  in  front 
of  this  is  the  sinus  prostaticus,  into  which  open  the  ejaculatory  ducts. 

The  membranous  urethra  is  that  part  which  extends  from  the  poste- 
rior to  the  anterior  layer  of  the  triangular  ligament,  and  is  about  three- 
fourths  of  an  inch  in  length.  It  lies  about  an  inch  below  the  symphysis 
pubis,  from  which  it  is  separated  by  the  dorsal  vessels  and  nerves  of  the 
penis  and  some  connective  and  muscular  tissue.  It  is  surrounded  by 
the  compressor  urethrae  muscle,  and  below  it,  and  on  either  side,  are 
Cowper's  glands.     It  is  the  narrowest  part  of  the  entire  canal. 

The  spongy,  pendulous,  or  penile  portion  begins  at  the  anterior  layer 


THE    GENITOURINARY  SYSTEM.  42 1 

of  the  triangular  ligament  and  extends  to  the  meatus  urinarius  at  the 
end  of  the  penis.  This  part  of  the  urethra  is  very  important  surgically, 
owing  to  the  persistence  with  which  the  gonococcus  maintains  its  posi- 
tion there.  This  is  accounted  for  by  the  abundant  supply  of  mucous 
glands  and  ducts  in  this  part  of  the  canal.  Once  infected,  the  ducts 
become  dilated,  their  orifices  obstructed,  and  the  glands  themseh^es 
filled  with  infective  products.  The  spongy  portion  of  the  urethra  is 
movable ;  the  membranous  and  prostatic  portions  are  fixed  and  form 
a  curve.  This  curve  extends  from  just  in  front  of  the  triangular  liga- 
ment to  the  neck  of  the  bladder.  It  is  represented  by  an  arc  of  a  circle 
three  inches  in  diameter,  and  subtended  by  a  chord  two  and  three-quar- 
ters inches  in  length. 

Rupture  of  the  Urethra. — In  the  pendulous  portion,  owing  to  its 
freedom  of  motion,  this  accident  is  rare.  Many  of  the  cases  met  with 
are  produced  during  coition,  and  are  readily  recognized  by  the  imme- 
diate sw^elling,  pain,  and  ecchymosis  of  the  whole  organ.  The  mem- 
branous portion  is  much  more  frequently  ruptured,  and  the  common 
cause  is  a  fall  astride  of  a  hard  or  resistant  body,  such  as  a  timber,  a 
plank,  or  a  ship's  spar,  by  which  the  urethra  is  forcibly  compressed 
between  such  object  and  the  triangular  ligament  or  possibly  the  pubic 
arch.  Other  causes  are  injuries  produced  by  the  use  of  instruments, 
the  giving  way  of  the  urethra  behind  a  tight  stricture,  and  fracture  of 
the  pubic  bones. 

Syniptonis. — Four  leading  symptoms  may  be  relied  upon  in  forming 
a  diagnosis  of  ruptured  urethra — viz.  pain,  disorder  of  micturition, 
hemorrhage,  and  the  formation  of  a  urinary  tumor. 

Pain  is  seldom  wanting :  it  may  be  so  slight  as  to  give  little  incon- 
venience, or  it  may  be  sudden  and  so  intense  as  to  cause  fainting.  It 
is  most  marked  at  the  seat  of  rupture,  but  may  spread  over  a  con- 
siderable area.  The  first  intensity  having  passed  away,  a  more  con- 
stant form  of  pain  is  produced  by  the  passage  of  urine  over  the 
lacerated  membrane. 

Micturition  is  interfered  wath  in  nearly  every  case,  but  the  variations 
of  this  symptom  are  numerous.  In  one  case  there  is  but  slight  dif- 
ficulty in  urinating  ;  in  another  there  is  complete  retention.  Sometimes 
there  is  retention  for  a  short  time,  after  which  the  flow  of  urine  is  per- 
fect. These  changes  are  explained  by  the  local  conditions.  The  ure- 
thra may  be  completely  divided,  the  ends  separated,  and  the  mucous 
membrane  curled  up.  Inflammation  in  and  around  the  urethra  may 
occlude  its  lumen,  and  thus  cause  retention  at  a  late  stage  of  the  dis- 
ease. Clots  forming  at  the  seat  of  injury  may  cause  a  temporary 
retention  which  passes  off  as  soon  as  the  coagula  have  been  ex- 
pelled. 

Hemorrhage  may  appear  at  the  meatus  urinarius  or  beneath  the 
skin  at  the  seat  of  injury,  or  in  both  situations.  The  quantity  of  blood 
is  subject  to  great  variation.  As  a  rule,  it  appears  immediately  after 
the  accident.  There  may  be  but  a  few  drops  of  blood  or  there  may  be 
a  continuous  oozing.  In  severe  cases,  in  which  mucous  membrane  is 
lacerated  and  the  corpus  spongiosium  freely  opened  into,  the  bleeding 
may  be  so  profuse  as  to  cause  death.  Ecchymosis  is  generally  present, 
of  varjnng  intensity  according  to  the  depth  of  the  rupture  and  severity 


422  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

of  the  traumatism.  It  is  most  marked  when  the  rupture  is  in  the  spongy 
portion  or  in  the  perineum.  It  is  wanting  or  appears  at  a  late  period 
when  the  rupture  is  caused  by  fracture  of  the  pelvis. 

Forjiiatioii  of  a  Tumor. — This  is  best  seen  in  ruptures  in  the  peri- 
neum. The  tumor  is  in  the  middle  line,  and  at  the  outset  is  not  larger 
than  a  pigeon's  egg.  Later  it  increases  in  size  to  almost  any  extent. 
By  pressure  it  can  be  diminished,  and  at  the  same  time  blood  or  urine, 
or  both,  escape  from  the  meatus.  In  the  pendulous  portion  the  tumor 
may  appear  as  a  small  node  or  it  may  surround  the  organ  like  a  collar. 

When  all  of  these  symptoms  are  present  there  is  no  difficulty  in 
arrivincf  at  a  diatjnosis,  but  in  the  absence  of  one  or  more  the  condition 
may  be  obscure.  The  history  of  the  injury  should  be  carefully  consid- 
ered, and  rupture  of  the  urethra  suspected  in  cases  of  severe  traumatism 
about  the  perineum  or  pelvis.  The  part  of  the  urethra  involved  can 
usually  be  made  out  by  passing  an  olive  bougie,  when  extreme  sensi- 
tiveness at  one  particular  spot  will  indicate  the  rupture.  Injuries  of  the 
perineum  are  followed  by  rupture  of  the  bulbar  portion  of  the  urethra, 
while  fracture  of  the  pelvis  usually  causes  rupture  of  the  membranous 
portion. 

Ti'catmeiit. — In  mild  cases,  attended  with  slight  hemorrhage  and  no 
extravasation  of  urine,  it  may  be  sufficient  to  pass  a  soft-rubber  catheter 
from  time  to  time,  keeping  the  patient  at  perfect  rest  and  watching  for 
complications.  In  more  severe  cases,  attended  with  considerable  hem- 
orrhage and  more  or  less  extravasation  of  urine,  it  will  be  necessary  to 
make  free  incisions  in  the  extravasated  area  and  retain  a  catheter 
constantly  in  the  bladder. 

In  the  most  severe  type  of  cases,  in  which  it  is  impossible  to  pass 
a  catheter,  perineal  section  should  be  made  without  delay,  the  divided 
ends  of  the  urethra  found,  and  the  catheter  passed  through  into  the 
bladder  and  retained  there.  This  is  sometimes  a  difficult  matter,  and  it 
may  be  utterly  impossible  to  find  the  proximal  end  of  the  urethra.  In 
that  ev^ent  it  is  advisable  to  make  a  suprapubic  cy.stotomy  and  relieve  the 
bladder  by  retrograde  catheterization.  When  it  is  possible  the  divided 
ends  of  the  canal  should  be  stitched  together.  The  best  material  is 
catgut ;  the  sutures  should  not  include  the  mucous  membrane,  and 
care  must  be  taken  lest  the  edge  of  the  membrane  gets  folded  into 
the  wound.  A  danger  of  ruptured  urethra  not  to  be  lost  sight  of  in 
treatment  is  its  tendency  to  be  followed  by  stricture. 

False  Passages  in  the  Urethra. — Unskilful,  rough,  or  careless 
use  of  a  catheter  or  sound  may  rupture  one  or  more  of  the  coats  of 
the  urethra  from  within,  and  produce  what  is  known  as  "  false  passages." 
Their  position  may  be  at  any  part  of  the  urethral  tract,  but  most  fre- 
quently in  the  neighborhood  of  the  bulb.  They  may  be  produced  in 
a  healthy  urethra  if  care  be  not  taken  to  lower  the  handle  of  the 
catheter  when  the  point  of  the  instrument  reaches  the  cul-de-sac  of  the 
bulb,  for  if  it  be  pushed  straight  on  it  will  pierce  the  lower  wall  of  the 
canal  and  pass  under  the  membranous  portion  between  the  prostate 
and  the  rectum.  If,  on  the  other  hand,  the  operator  lower  the  handle 
too  soon,  the  point  perforates  the  anterior  wall  of  the  urethra  and 
passes  behind  the  symphysis  pubis.  False  passages,  however,  are 
much  more  commonly  met  with  when  there  is  some  abnormal  condi- 


THE    GENITO-URINARY  SYSTEM.  423 

tion  of  the  urethra.  Stricture  is  a  very  common  cause,  and  so  is 
enlargement  of  one  or  other  of  the  lobes  of  the  prostate. 

Diagnosis. — If  during  the  passage  of  a  catheter  or  sound  an  obstruc- 
tion be  met  with,  which  is  suddenly  overcome  and  attended  with  a 
tearing  sensation,  which  the  surgeon  can  feel  and  the  patient  can  also 
appreciate  ;  if  on  withdrawal  of  the  instrument  there  is  no  grasping  of 
it  by  the  urethra  ;  and  if,  moreover,  a  few  drops  of  blood  escape  after 
the  catheter  is  withdrawn, — it  is  pretty  certain  that  the  instrument  is 
making  a  false  passage.  Should  the  operator  under  these  conditions 
be  so  foolhardy  as  to  insist  upon  pushing  the  instrument  to  its  desti- 
nation, he  will  find  that  it  progresses  with  a  series  of  jerks,  instead  of  a 
smooth,  steady  motion  ;  and  if  the  finger  be  inserted  into  the  rectum, 
the  instrument  will  be  found  to  have  travelled  to  one  or  other  side  of 
the  middle  line,  and  can  be  felt  too  close  to  the  rectal  wall. 

Old  false  passages  are  sometimes  confusing.  You  may  pass  a 
catheter  to  a  certain  point,  and  there  it  becomes  arrested.  The  ques- 
tion naturally  arises,  Is  this  obstruction  due  to  a  stricture  or  to  a  false 
passage  ?  If  the  patient  can  urinate  at  any  time  with  ordinary  freedom, 
there  is  no  stricture.  If  in  the  passage  of  the  instrument  it  is  found  to 
deviate  to  one  or  other  side  of  the  median  line,  it  is  evidence  that  there 
is  a  false  passage. 

Treatment. — Minor  lacerations  made  with  a  small  instrument  seldom 
require  any  active  treatment.  False  passages  made  by  a  large  instrument 
and  involving  considerable  extent  of  tissue  require  careful  attention. 

A  catheter  should  be  passed  into  the  bladder  and  retained  for 
several  days.  This  will  serve  the  double  purpose  of  relieving  retention 
and  of  exerting  pressure  upon  the  walls  of  the  false  passage,  and  thus 
favoring  its  repair.  If  it  is  impossible  to  pass  a  catheter,  and  the 
patient  is  still  able  to  micturate,  perfect  rest  and  antiphlogistic  treat- 
ment are  sufficient.  If,  however,  there  be  complete  retention  and  the 
catheter  cannot  be  passed,  external  urethrotomy  or  suprapubic  cys- 
totomy with  retrograde  catheterization  is  indicated. 

Foreign  Bodies  in  the  Urethra. — These  may  come  from  the 
bladder,  as  fragments  of  calculi,  or  they  may  be  pushed  into  the  urethra 
from  without,  or  may  occur  by  accident,  as  when  a  catheter  or  other 
instrument  is  broken  during  its  passage.  In  any  case  the  diagnosis  is 
not  difficult.  The  stream  of  urine  is  more  or  less  interfered  with,  and 
may  be  suddenly  stopped,  as  when  a  small  calculus  from  the  bladder 
completely  blocks  the  passage.  Palpation  along  the  course  of  the 
penile  portion  of  the  urethra  will  reveal  the  presence  of  a  foreign  body, 
not  only  by  the  sense  of  touch,  but  by  the  localized  tenderness.  The 
deep  urethra  may  be  palpated  by  the  finger  in  the  rectum,  and  the  diag- 
nosis may  be  completed  by  passing  a  metallic  instrument  into  the 
urethra. 

Diagnosis  of  Calculus  coming  from  tJie  Bladder  and  becoming  Lodged 
in  the  Urethra. — A  calculus  may  be  arrested  at  any  portion  of  the 
urethra,  but  the  commonest  situations  are  the  two  narrowest  portions 
of  the  canal — viz.  the  neck  of  the  bulb  and  the  fossa  navicularis.  If 
the  stone  be  very  small,  it  may  produce  only  a  difficulty  in  passing 
water ;  if  large  enough  to  block  the  urethra,  an  abrupt  retention  may 
result.     This  is  more  common  in  children ;  the  rule  in  adults  is,  that 


424  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

pain  is  first  felt  in  the  rei;ion  of  the  kidneys,  followed  by  the  expulsion 
of  gravel.  The  degree  of  pain  varies  with  the  size  and  shape  of  the 
stone.  It  may  be  almost  wanting  when  the  calculus  is  small,  round, 
and  smooth,  while  in  the  case  of  a  large  stone  with  roughened  surface  the 
suffering  may  be  intense.  After  palpating  the  urethra  as  already  men-, 
tioned  a  sound  should  be  passed.  A  calculus  of  considerable  size  will 
check  the  passage  of  the  instrument,  and  a  distinct  click  will  leave  no 
doubt  as  to  the  character  of  the  obstruction.  Some  idea  may  also  be 
gained  of  the  consistence  of  the  stone  and  the  character  of  its  surface. 
A  small  stone  may  allow  the  sound  to  pass  by  without  giving  any  indi- 
cation to  the  hand  which  holds  the  instrument,  but  in  the  vast  majority 
of  cases  there  will  be  felt  a  sensation  of  rubbing  or  grating. 

It  may  happen  that  the  stone  lies  in  a  pouch  or  pocket,  and  is  not 
touched  by  the  instrument.  Palpation  must  be  depended  upon  to  find 
a  tumor  in  the  neighborhood  of  the  penile  or  deep  urethra,  and  while 
the  palpating  finger  is  kept  in  close  contact  with  the  tumor  a  sound  can 
be  i^assed  and  its  end  directed  against  the  suspected  spot. 

A  stone  in  the  prostatic  or  membranous  portion  of  the  urethra  may 
be  confounded  with  a  tumor  of  the  prostate  or  with  a  urinary  abscess. 
The  history  of  the  case  must  be  carefully  considered.  If  the  patient 
has  habitually  passed  gravel,  the  presumption,  ceteris  paribus,  is  very 
strong  in  favor  of  the  idea  that  the  body  is  a  calculus.  If  the  sound 
click  against  a  stone  very  deep  in  the  urethra,  the  question  may  arise 
as  to  whether  the  calculus  is  in  the  urethra  or  at  the  neck  of  the  blad- 
der. To  settle  this  point  a  digital  examination  of  the  rectum  should  be 
made  and  the  membranous  and  prostatic  portions  of  the  urethra  care- 
fully palpated.  With  the  finger  still  in  the  rectum  lift  the  prostate  well 
up  toward  the  pubis  and  pass  a  catheter  having  an  opening  at  its  tip. 
Watch  for  the  first  flow  of  urine.  If  the  stone  can  be  touched  without 
the  escape  of  urine,  the  calculus  is  in  the  urethra.  If  urine  begins  to 
flow  the  moment  the  stone  is  touched,  it  is  in  the  bladder. 

Treatment. — The  stone  may  be  removed  by  one  of  three  different 
routes  : 

1.  By  the  meatus.  The  fossa  navicularis,  being  one  of  the  narrow 
parts  of  the  urethra,  sometimes  contains  a  calculus,  which  can  be  read- 
ily removed  through  the  meatus  with  or  without  enlargement  of  the 
orifice  by  incision.  When  the  stone  is  farther  back  its  removal  is 
attended  with  more  difficulty.  A  probe  should  be  passed  in  and  the 
calculus  loosened  from  its  position,  after  which  the  meatus  is  pinched 
between  the  fingers  while  the  patient  is  asked  to  micturate  and  strain  with 
all  his  might.  In  this  way  the  stone  may  be  passed  or  brought  within 
reach  of  forceps.  A  number  of  instruments  have  been  invented  with 
the  view  of  either  removing  the  foreign  body  or  crushing  it  in  situ ; 
but  as  their  employment  is  attended  wdth  considerable  laceration  of  the 
urethra,  it  is  better  to  use  only  a  fine  pair  of  forceps  (Fig.  183).  Should 
it  be  found  impossible  to  grasp  and  remove  the  stone,  an  external 
urethrotomy  will  be  found  less  hazardous  and  more  satisfactory  than 
persistence  in  the  use  of  instruments. 

2,  By  the  bladder.  When  the  stone  is  in  the  membranous  or  pros- 
tatic portions  of  the  urethra  a  full-sized  metallic  sound  maybe  inserted 
with  the  object  of  pushing  it  back  into  the  bladder.    It  is  then  a  vesical 


THE    GENITO-URINARY  SYSTEM.  425 

calculus,  and  can  be  crushed  with  the  lithotrite  and  removed  imme- 
diately or  at  some  future  time. 

3.  By  an  urethral  incision.  The  most  suitable  cases  for  this  opera- 
tion are  those  in  which  the  stone  is  in  the  spongy  portion  of  the  ure- 
thra. It  is  also  applicable  when  the  stone  cannot  be  pushed  back  into 
the  bladder.  The  operation  is  done  as  follows  ,  Steady  the  stone  with 
the  thumb  and  finger  and  cut  down  upon  it,  making  the  incision  just 
large  enough  to  extract  the  stone.  After  its  removal  pass  a  soft  cath- 
eter into  the  bladder  and  retain  it  there.  The  wound  may  be  closed 
with  several  sutures  or  allowed  to  heal  by  the  open  method.  When 
stone  in  the  urethra  is  complicated  with  a  stricture,  one  of  several 
procedures  must  be  adopted  according  to  circumstances  : 

{a)  If  the  calculus  be  small  and  the  patient  can  pass  water,  the 
stricture  should  be  dilated  and  the  stone  removed  by  the  force  of  the 
urine  or  by  the  aid  of  urethral  instruments. 

{b)  When  the  patient  is  unable  to  urinate  and  it  is  necessary  to 
remove  the  calculus  immediately,  the  stricture  can  be  disposed  of  by 
an  internal  urethrotomy,  when  the  stone,  if  sufficiently  small,  can  be 


Fig.  183. — Thompson's  urethral  forceps. 

withdrawn,  or  the  urethra  can  be  opened  from  without  (external 
urethrotomy)  and  both  stricture  and  stone  disposed  of  The  latter 
procedure  is  in  the  majority  of  cases  to  be  preferred. 

Foreign  bodies  introduced  into  the  urethra  by  the  meatus  afford 
practically  the  symptoms  described  under  Calculi  in  the  Urethra,  and 
their  removal  is  effected  on  the  same  principle. 

Urethritis,  or  Inflammation  of  the  Urethra. — All  inflamma- 
tions of  the  urethra  may  be  divided  into  two  great  classes — those  due  to 
a  simple  inflammation  of  the  mucous  membrane,  and  those  the  result 
of  infection  by  a  specific  germ,  the  gonococcus. 

Simple  urethritis  may  arise  from  any  traumatism  to  the  urethra,  as 
the  rough  passage  of  a  catheter,  the  laceration  of  the  tissues  by  calculi, 
or  the  exposure  to  irritating  and  unhealthy  discharges,  as  those  which 
come  from  a  cancerous  uterus  or  a  metritis  or  cervacitis.  Inflammation 
arising  in  this  ^yay  is  scarcely  to  be  distinguished  from  a  specific  gonor- 
rhea, except,  perhaps,  that  it  is  of  shorter  duration  and  of  less  severity. 
It  is  well  to  remember,  in  diagnosis,  that  such  a  disease  as  simple  ure- 
thritis exists,  and  not  every  case  of  purulent  discharge  from  the  urethra 
need  reflect  upon  the  character  or  virtue  of  the  person  so  affected. 

Gonorrhea. — Urethritis  due  to  the  presence  of  the  gonococcus  is 
very  conveniently  classified  under  three  varieties:  i.  Acute  inflamma- 
tion, or  typical  gonorrhea ;  2.  Subacute  or  catarrhal  gonorrhea ;  3. 
Irritative  or  abortive  gonorrhea. 


426  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

Acute  inflammatory  or  typical  f^onorrhea  is  the  variety  most  fre- 
quently met  with,  and  is  therefore  very  important  as  a  clinical  study. 
A  patient  suffering  from  this  disease  may  be  compared  to  a  man 
climbing  a  steep  hill,  then  crossing  a  broad  tableland,  and  finally 
descending  to  the  plain  on  the  other  side ;  for  the  disease  has  three 
stages — viz.  the  first  or  increasing  stage,  the  second  or  stationary 
stage,  and  the  third  or  stage  of  subsidence. 

Like  other  contagious  diseases,  gonorrhea  has  a  period  of  incubation 
varying  from  a  few  hours  to  fourteen  days,  but  it  is  safe  to  say  that  the 
disease  begins  to  manifest  itself  within  a  week  after  exposure  to  the 
virus. 

The  first  symptoms  to  attract  the  patient's  attention  is  a  drop  of 
thin  milky  fluid  appearing  at  the  meatus  ;  there  is  also  an  itching  or 
tickling  sensation,  and  the  lips  of  the  meatus  are  red,  everted,  and 
slightly  swollen.  Micturition  is  attended  with  a  sense  of  warmth  at 
first,  which  speedily  increases  to  scalding,  and  within  forty-eight  hours 
or  even  sooner  the  first  or  increasing  stage  is  so  fully  developed  as  to 
leave  no  possible  doubt  as  to  the  nature  of  the  disease.  During  this 
stage  the  following  symptoms  become  pronounced :  The  meatus  is  red, 
ev^erted,  swollen,  and  sometimes  eroded.  The  swelling  may  be  sufficient 
to  almost  close  the  opening,  so  that  the  urine  is  passed  in  drops. 
Pressure  on  the  penis  along  the  course  of  the  urethra  is  painful,  and  if 
It  be  made  in  the  direction  of  the  meatus,  a  thick,  yellowish,  purulent 
discharge  escapes.  This  is  a  good  way  of  testing  the  veracity  of  per- 
sons who  deny  that  they  have  been  exposed  to  infection.  My  memory 
reverts  to  an  honored  teacher  who  in  his  wards  often  met  with  cases  of 
this  character.  With  no  gentle  touch  he  was  in  the  habit  of  grasping 
the  penis  between  his  finger  and  thumb  and  sliding  them  along 
toward  the  meatus,  causing  the  fluid  to  exude.  If  satisfied  that  the 
patient  was  lying,  he  turned  upon  his  heel  and  silently  walked  away, 
leaving  the  man's  feelings  and  urethra  literally  crushed. 

Scalding  attends  every  act  of  micturition. 

Clwrdcc,  or  painful  erection,  is  not  a  symptom  in  every  case,  but  is 
quite  common.  It  generally  comes  on  at  night,  and  just  about  the  time 
the  patient  is  ready  to  fall  asleep.  The  organ  is  usually  curved  down- 
w^ard,  rarely  upward  or  laterally  or  twisted.  The  erection  or  priapism 
is  very  painful  and  persistent.  The  dangers  of  chordee  are  rupture  and 
hemorrhage,  which  may  terminate  in  organic  stricture  or  in  abscess. 

Frequent  urination  and  vesical  tenesmus  are  sometimes  present  in 
this  stage  of  the  disease,  and  may  be  taken  as  indications  that  the 
inflammation  has  spread  along  the  urethra  tow'ard  the  bladder. 

During  the  first  or  increasing  stage  complications  are  likely  to 
supervene.  The  inflammation  may  extend  from  the  meatus  to  the  sur- 
face of  the  glans  penis,  producing  redness  and  other  signs  of  inflam- 
mation, and  sometimes  ending  with  exfoliation  of  the  epithelium, 
leaving  the  glans  eroded  or  ulcerated.  This  complication  is  known  as 
balanitis.  When  the  erosions  or  ulcerations  are  pronounced  it  is  possi- 
ble to  mistake  the  condition  for  chancrous  erosion.  In  the  latter, 
however,  there  is  no  urethral  discharge,  there  is  induration  at  the  base 
of  the  ulcer,  the  sore  itself  is  clearly  defined  and  not  acutely  inflamed, 
and  the  lymphatic  glands  are  involved. 


THE    GENITO-URINARY  SYSTEM. 


427 


From  the  glans  penis  the  inflammation  may  spread  over  the  inner 
surface  of  the  prepuce.  This  compHcation  is  called  balano-posthitis. 
The  swelling  of  the  prepuce  and  its  infiltration  with  inflammatory- 
products  result  in  the  third  complication,  which  is 

Phimosis. — In  this  troublesome  condition  the  prepuce  covers  the 
glans  penis  (Fig.  1 84),  and  cannot  be  retracted  ;  discharges  are  retained, 
making  it  exceedingly  difficult  to  keep  the  parts  clean  or  to  give  them 
proper  treatment.  If  the  patient  is  in  this  condition  when  he  first 
presents  himself  for  advice,  the  diagnosis  may  be  somewhat  difficult. 
The  existence  of  phimosis  is  clear  enough,  but  how  are  we  to  say 
whether  the   primary  disease  is  gonorrhea  or  chancroid  beneath  the 


Fig.  184. — Phimosis  with  luddcn  chancre  (frum  a  photograph  in  the  collection  of  Dr.  Lincoln). 

prepuce  ?     Attention  to  the  following  points  will  generally  clear  up  the 
question  : 

1.  History. — In  gonorrhea  there  is  a  history  of  simple  scalding 
during   micturition,  but  no  sore. 

2.  The  discharge  in  gonorrhea  is  purulent ;  in  chancroid  it  is  often 
mixed  with  blood. 

3.  Chordee  is  sometimes  present  in  gonorrhea,  but  is  never  a  marked 
symptom  in  chancroid. 

4.  Scalding  is  felt  along  the  course  of  the  urethra  in  gonorrhea ; 
only  at  the  prepuce  in  chancroid. 

Treatment  of  Phimosis. — A  lotion  containing  acetate  of  lead  and 
tincture  of  opium  should  be  used  to  allay  the  inflammation  in  the  pre- 
puce. The  part  beneath  the  prepuce  should  be  syringed  with  soap  and 
water  and  afterward  washed  with  the  lotion.  In  most  cases  this  treat- 
ment will  allay  the  swelling  sufficiently  to  allow  of  the  prepuce  being 
drawn  back. 

When  all  other  means  have  failed  circumcision  is  indicated. 

Another  complication  of  this  stage  of  gonorrhea  is  parapliiuwsis.  It 
also  is  a  result  of  inflammation  in  the  prepuce.  If,  in  its  swollen  condition, 
it  should  happen  to  be  retracted  and  become  caught  behind  the  corona 
glandis,  the  constriction  increases  so  rapidly  that  the  prepuce  cannot  be 


428  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

brou<j^ht  forward.  The  glans  become  swollen  ;  the  prepuce,  puffy  and 
edematous,  forms  a  collar  behind  the  corona;  and  a  little  farther  back 
is  a  tight,  unyielding  ring  formed  by  the  orifice  of  the  prepuce. 

Trcattnoit  of  Paraphiuiosis. — Oil  the  parts  and,  placing  your  two 
thumbs  on  the  glans,  with  the  fore  fingers  above  and  behind  the  corona 
glandis  and  the  middle  fingers  below  and  beneath,  make  gentle  pres- 
sure upon  the  glans  until  its  congested  vessels  are  emptied  and  it  can  be 
pushed  back  within  the  prepuce  and  the  latter  drawn  well  forward. 

Or  the  end  of  the  penis  may  be  wrapped  in  a  piece  of  moist  lint  two 
inches  in  width  and  extending  a  little  in  front  of  the  glans.  Around 
this,  from  before  backward,  is  wound  a  piece  of  round  elastic  ligature. 
In  this  way  the  glans  is  so  compressed  that  it  can  be  pushed  back 
within  the  prepuce  (hkidowes). 

Strapping  the  glans  and  jjrepuce  with  adhesive  plaster  and  leaving 
them  under  pressure  for  twent)'-four  hours  will  often  bring  the  parts 
into  proper  condition. 

Failing  in  all  of  these  measures,  the  constriction  should  be  divided. 
This  is  done  by  passing  beneath  the  prepuce  or  the  dorsum  a  thin  knife 
and  turning  its  edge  upward  against  the  furrow  which  lies  between  the 
mucous  membrane  and  the  skin.  If  unrelieved,  ulceration  and  slough- 
ing are  sure  to  follow  ;  the  pain  throughout  is  severe,  and  altogether  the 
condition  is  troublesome  and  dangerous.  Thus,  the  patient  toils  wearily 
up  the  hill,  which  represents  the  first  or  increasing  stage,  tormented  by 
day  with  frequent  calls  to  urinate  and  dreading  the  scalding  which 
attends  the  act ;  tortured  by  night  with  painful  priapism  ;  disgusted  with 
the  filthy  discharge  which  continuously  escapes  from  his  meatus  ;  and 
filled  with  remorse  for  the  folly  which  led  him  from  the  path  of  virtue. 
The  duration  of  this  stage  is  variable,  but  if  properly  treated  it  should 
not  exceed  a  week,  and  the  second  or  stationary  stage  begins. 

Syviptoms  of  the  Second  or  Stationary  Stage. — During  this  stage 
the  inflammation  is  extending  backward  along  the  urethra.  The 
symptoms  of  the  first  stage  continue  unchanged,  and  as  deeper 
portions  of  the  urethra  become  involved  new  complications  arise, 
depending  upon  the  part  or  tissue  to  which  the  inflammatory  action 
spreads.  Attacking  the  follicles  which  open  upon  the  surface  of  the 
urethra,  it  causes  swelling  of  their  lining  membrane,  occluding  their 
orifices  and  converting  them  into  small  abscesses.  These  can  be  felt 
as  small  round  tumors  along  the  under  surface  of  the  urethra.  They 
usually  open  internally,  rarely  through  the  skin.  Extending  beyond 
the  follicles,  the  connective  tissue  which  surrounds  the  urethra  may 
become  involved,  giving  rise  to  periurethral  abscesses,  especially 
at  the  fossa  navicularis  and  the  anterior  part  of  the  membranous 
urethra. 

Bubo  is  a  complication  frequently  met  with.  It  is.  the  result  of  the 
inflammatory  process  extending  to  the  glands  of  the  groin.  The  first 
manifestation  is  a  small  painful  tumor  just  below  Poupart's  ligament, 
and  which  is  one  of  the  superficial  glands.  It  becomes  swollen  and 
inflamed,  but  under  proper  management  subsides  before  suppuration 
takes  place. 

Treatment  of  Bubo. — Simple  pressure  or  the  application  of  iodin  is 
often  sufficient  to  prevent  suppuration.     This,  failing,  fomentations  of 


THE    GENITO-URINARY  SYSTEM.  429 

hot  sublimate  solution  should  be  kept  constantly  applied,  and  when  an 
abscess  forms  it  should  be  lanced  and  treated  in  the  usual  way. 

Extending  to  the  prostate  and  bladder,  the  symptoms  characteristic 
of  prostatitis  and  cystitis  respectively  must  be  sought  for.  They  have 
been  already  discussed. 

The  Third  Stage,  or  Stage  of  Subsidence. — The  second  stage  lasts 
from  one  to  two  weeks,  when,  one  by  one,  the  troublesome  symptoms 
begin  to  subside.  The  discharge  becomes  scanty  or  entirely  disappears, 
the  urine  is  voided  without  inconvenience,  chordee  becomes  a  thing  of 
the  past,  and  there  is  a  gradual  return  to  healthy  conditions.  The 
patient  has  ascended  the  hill,  crossed  the  tableland,  and  is  descending 
to  the  plain  on  the  other  side.  Still,  he  is  beset  with  dangers  from 
which  he  has  to  be  carefully  guarded.  The  slightest  indiscretion  may 
start  up  the  discharge ;  the  inflammation  may  take  a  new  course,  pass- 
ing along  the  ejaculatory  ducts  and  invading  the  testicle.  This  is  a 
troublesome  complication,  and  may  come  on  as  late  as  the  end  of  the 
second  or  even  the  third  month.  This  is  known  as  epididymitis,  or 
gonorrheal  szuelled  testicle.  The  symptoms  begin  with  pain  in  the 
groin  (usually  the  left),  followed  by  a  dull  aching  in  the  testicle  itself 
When  the  cord  is  palpated  it  is  found  to  be  swollen  and  tender.  The 
testicle  soon  begins  to  swell  and  may  attain  an  immense  size,  the  scro- 
tum assumes  a  purple  color,  and  the  patient  constantly  complains  of  a 
nauseating  pain.  AH  these  symptoms  are  aggravated  if  the  large  and 
heavy  testicle  is  allowed  to  hang  down  and  cause  dragging  by  its 
weight.  Sometimes  the' induration  in  the  cord  and  neighboring  tissues, 
combined  with  nausea  and  vomiting,  simulate  hernia — a  point  which  is 
worth  keeping  in  view,  as  errors  in  diagnosis  may  thus  occur. 

Gonorrheal  rheumatism  is  a  complication  which  may  occur  at  any 
time  and  in  any  form  of  gonorrhea.  The  patient  may  or  may  not  be 
predisposed  to  rheumatic  affections.  The  symptoms  are  frequently 
ushered  in  with  a  chill,  followed  by  slight  fever,  and  the  appearance  of 
pain  and  swelling  in  one  of  the  joints,  notably  the  knee,  ankle,  wrist,  or 
elbow.  The  pain  on  movement  is  intense,  and  the  synovial  fluid  is 
increased,  amounting  in  some  cases  to  a  marked  synovitis  or  even  a 
general  arthritis.  Besides  the  joints,  the  disease  may  involve  the 
muscles,  the  tendons,  tendon-sheaths,  and,  more  rarely,  the  sheaths 
of  nerves.  The  course  of  this  variety  is  generally  more  mild  than 
that  of  ordinary  articular  rheumatism,  from  which  it  differs  in  the 
following  particulars  :  Gonorrheal  rheumatism  is  associated  with  ure- 
thritis ;  the  fever  is  slight ;  there  is  no  sweating ;  the  urine  remains 
unaltered ;  and  antirheumatic  remedies  do  no  good.  It  is  almost  sure 
to  return  with  each  subsequent  attack  of  urethritis. 

Ophthalmia  and  conjiuictivitis  are  also  complications  of  gonorrhea. 

Subacute  or  Catarrhal  Gonorrhea. — The  first  attack  of  urethritis  due 
to  the  gonorrheal  virus  is  nearly  always  acute.  A  person  having  passed 
through  one  is  liable  to  subsequent  attacks,  which  may  be  brought  on 
by  simple  irritants,  such  as  contact  with  leukorrheal  secretion  or  a  fresh 
infection.  These  recurrences  are  much  milder  and  assume  a  catarrhal 
or  subacute  character.  The  pain  during  micturition  is  slight ;  chordee, 
if  a  symptom,  is  never  of  the  painful  kind  which  attends  acute  attacks, 
and  complications  are  wanting.     The  discharge  is  never  so  profuse  as 


430  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

in  the  acute  variety,  and  it  rapidly  diminishes  under  treatment.  It  is 
not  uncommon,  however,  to  have  the  dischar,<;e  hnger  along  for  an 
indefinite  period,  and  only  visible  in  the  morning — the  so-called 
"  morning  drop." 

Irritative  or  Abortive  Gonorrhea. — In  this  variety  the  symptoms  are 
of  the  mildest  kind,  confined  to  the  meatus  and  fossa  navicularis,  and 
stopping  there.  There  is  little  if  any  scalding  in  micturition  ;  the  dis- 
charge is  slight  and  transparent,  and  if  let  alone  stops  within  a  week. 
These  are  the  cases  which  give  glory  to  the  so-called  abortive  treat- 
ment and  to  the  charlatans  who  promise  "  a  perfect  cure  in  three  days." 

Treatment  of  Goiiorr/iea. — A  great  deal  has  been  written  upon  the 
treatment  of  gonorrhea,  and  an  endless  list  of  remedies  might  be  com- 
piled which  from  time  to  time  have  been  lauded  as  certain  and  speedy 
cures. 

Two  lines  of  treatment  must  be  considered  : 

I.  The  Abortive  Treatment. — With  the  idea  of  destroying  the  gono- 
cocci  and  cutting  short  the  urethritis  which  results  from  their  presence 
various  remedies  have  been  employed.  These  are  antiseptics  and 
caustics.  At  first  sight  the  idea  -seems  quite  feasible.  Infection  begins 
at  the  meatus  and  extends  backward  along  the  urethra.  If  the  germs 
can  be  destroyed  before  they  have  had  time  to  proliferate  and  thor- 
oughly infect  the  tissues,  the  disease  is  aborted.  This  is  "  a  consum- 
mation devoutly  to  be  wished,"  but,  unfortunately,  clinical  experience 
goes  to  prove  that  the  attempt  is  rarely,  if  ever,  successful.  About 
all  that  we  can  say  in  favor  of  the  treatment  is  that  it  is  free  from  dan- 
ger, and  in  well-selected  cases  may  be  given  a  trial ;  but  he  who  tries  it 
will  probably  use  it  but  once.  Nitrate  of  silver  is  the  favorite  remedy, 
and  it  can  be  used  in  a  weak  or  strong  solution.  When  a  strong  solu- 
tion is  employed,  it  is  with  the  idea  of  destroying  the  virus  at  one  injec- 
tion ;  when  a  weak  solution  is  chosen,  it  is  with  the  hope  that  by  fre- 
quent injections  the  same  purpose  may  be  accomplished.  The  method 
of  using  the  strong  solution  is  as  follows :  A  small  syringe  with  a  long 
nozzle  is  filled  with  a  solution  of  silver  nitrate  (fifteen  grains  to  the 
ounce),  and  passed  into  the  urethra  to  a  depth  of  two  inches  ;  as  the 
instrument  is  slowly  withdrawn  the  fluid  is  injected  and  held  for  a  few 
seconds.  A  weak  solution  of  bicarbonate  or  of  chlorid  of  sodium  is 
then  injected,  and  the  patient  directed  to  expel  the  whole  by  urinating. 

The  weak  solutions  are  used  of  a  strength  of  one  half-grain  to  the 
ounce,  and  the  injections  are  made  every  two  hours  until  pronounced 
smarting  is  felt  during  micturition. 

Prolonged  and  systematic  irrigation  of  the  anterior  urethra  with  a 
solution  of  permanganate  of  potassium  in  a  strength  of  i  :  10,000  to 
I  :  5000,  as  first  practised  by  Janet  of  Paris  and  improved  by  the  appa- 
ratus devised  by  Valentine  of  New  York,  is  an  excellent  method  of 
treatment.  The  fluid  is  injected  as  warm  as  can  be  comfortably  borne, 
and  the  irrigation  kept  up  for  a  half  or  three-quarters  of  an  hour  at  a 
time,  twice  daily  during  the  first  three  or  four  days,  after  which  time  it 
is  given  once  a  day  for  two  or  three  weeks.  If  this  treatment  is  em- 
ployed, it  must  be  kept  up  for  several  weeks,  even  if  the  discharge 
stops  after  the  first  twenty-four  hours. 

The  danger  attending  the  employment  of  caustics  is  the  production 


THE    GENITO-URINARY  SYSTEM.  43  I 

of  stricture  and  the  possibility  of  converting  a  simple  irritative  or  abort- 
ive attack  of  urethritis  into  an  acute  inflammatory  form  of  the  disease. 

2.  The  second  method  of  treatment  is  based  upon  the  belief  that 
the  disease  is  self-limiting,  and  may  be  called  the  rational  treatment. 
We  have  already  seen  that  an  acute  inflammatory  urethritis  has  three 
stages — the  increasing,  the  stationary,  and  the  subsidiary — each  of 
which  occupies  about  a  week.  If  instead  of  making  a  desperate 
attempt  to  avert  the  disease,  we  resort  to  mild  remedies  which  will 
diminish  the  severity  of  the  symptoms,  avert  complications,  and  prevent 
unpleasant  after-effects,  we  will  secure  better  results  than  have  ever 
been  obtained  by  the  more  heroic  modes  of  treatment. 

Rest,  as  in  every  other  inflammatory  affection,  is  entitled  to  the  very 
first  consideration.  The  ideal  way  for  a  patient  to  act  during  the  course 
of  acute  urethritis  would  be  to  remain  perfectly  at  rest  in  bed.  This, 
however,  is  not  practicable,  and  the  most  we  can  insist  upon  is  that  the 
patient  take  as  much  rest  as  possible,  lying  down  when  he  has  an 
opportunity,  sitting  instead  of  standing,  and  riding  instead  of  walking. 
Sexual  excitement  must  be  avoided.  The  urine  should  be  kept  as 
unirritating  as  possible  by  attention  to  diet  and  by  the  use  of  remedies 
to  correct  abnormal  conditions.  With  this  end  in  view  alcoholic  and 
malt  liquors,  tea,  coffee,  and  highly  seasoned  articles  must  be  avoided, 
and  meat  of  all  kinds  used  most  sparingly.  As  much  as  it  is  possible 
for  him  to  do  so  the  patient  should  live  upon  bread  and  milk,  and  if  he 
can  confine  himself  to  these  two  articles,  so  much  the  better.  AlkaHne 
mineral  waters  are  valuable  in  diluting  the  urine  and  causing  it  to  pro- 
duce less  irritation  as  it  passes  over  the  inflamed  urethral  surface.  For 
similar  reasons  plain  water  may  be  freely  consumed.  Tobacco  seems 
to  have  a  very  deleterious  effect  and  should  as  far  as  possible  be  avoided. 

The  discharge  from  the  urethra  demands  careful  attention,  and  the 
utmost  cleanhness  should  be  insisted  on.  Frequently  soaking  the  penis 
in  warm  water  not  only  tends  to  keep  it  clean,  but  allays  inflammation 
and  pain  and  palliates  chordee.  As  a  dressing  the  simplest  contrivance 
is  a  small  stocking  or  muslin  bag  pinned  to  the  underclothing,  and  in 
which  the  penis  hangs  without  touching  the  lowest  portion,  this  part 
being  filled  with  absorbent  cotton,  which  retains  the  discharge  as  it 
drops  from  the  meatus. 

Internal  Remedies. — If  in  the  early  stage  of  acute  inflammatory 
urethritis  the  febrile  symptoms  play  a  prominent  part,  aconite  or  vera- 
trum  viride  is  useful.  To  render  the  urine  bland  and  unirritating  alka- 
Hne  diuretics  and  diluent  drinks  should  be  given  throughout  the  in- 
creasing stage.  Balsamic  preparations  have  long  been  held  in  high 
esteem.  The  best  of  these  is  the  oil  of  sandalwood,  which  can  be 
given  in  capsules  containing  ten  to  fifteen  minims  four  times  a  day. 
Cubebs  is  an  old-time  favorite,  and  may  be  given  in  doses  of  one  dram 
of  the  powder  three  times  a  day  or  in  the  following  mixture : 

I^.  Ol.  cubebae,  5ss  ; 

Ol.  cinnamom.,  TTLx  ; 

Spt.  eth.  nit.,  5ss  ; 

Mucil.  acacias,  ad  3viij. 

Sig.  One  tablespoonful  three  times  a  day. 


432  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

For  the  relief  of  chordee  the  patient  should  avoid  sexual  excite- 
ment, his  room  should  be  cool  and  well  ventilated,  food  should  not  be 
taken  late  in  the  evx-ning,  and  the  bowels  should  be  kept  relaxed.  For 
the  relief  of  the  painful  erection  bromide  of  potassium,  30  to  40  grains 
at  bedtime,  is  valuable.  A  suppository  containing  a  quarter-grain  of 
morphin  or  morphia  with  h)oscyamus,  or  a  hypodermic  of  morphia  in 
the  perineum,  given  at  bedtime,  will  usually  secure  a  night's  rest  should 
other  measures  fail,  care  being  taken  to  keep  the  bowels  from  becom- 
ing constipated. 

Urethral  Injections. — The  possibility  of  treating  the  urethra  on  anti- 
septic principles  has  received  a  great  deal  of  attention.  The  question 
is  a  difficult  one  from  the  fact  that  there  is  almost  invariably  a  double 
infection — viz.  the  gonococcus  of  Neisser  and  the  germs  of  suppura- 
tion. The  difficulty  is  further  increased  from  the  fact,  now  well  estab- 
lished by  experiment,  that  a  germicide  which  readily  destroys  pyogenic 
organisms  has  no  effect  upon  the  gonococcus.  A  list  of  the  drugs 
that  have  been  used  as  injections  and  lauded  as  specifics  would  fill  a 
volume.  In  the  first  few  days  of  the  increasing  stage  only  the  mildest 
injections  can  be  borne.  The  following  is  a  sedative  injection  suitable 
under  such  conditions  : 

I^.  Acid,  boric,  3j ; 

Morph.  acetat.,  gr.  iss  ; 

Cocain.  muriat.,  gr.  x  ; 

Aquae  dest.,  5vj. 

When  the  more  acute  symptoms  have  subsided  mild  astringents  and 
antiseptics  may  be  used  to  abate  the  discharge : 

^.  Zinci  sulphocarbolate,  gr.  xv  ; 

Hydrarg.  bichloridi,  gr.  -jIq-; 

Aqua  dest.,  ,^iv. 

Before  using  any  injection  it  is  necessary  to  w^ash  out  the  urethra 
with  warm  water,  which  of  itself  is  of  decided  benefit,  not  only  on 
account  of  its  cleansing  effect,  but  also  owing  to  its  soothing  properties. 

During  the  stationary  stage,  if  the  discharge  shows  no  signs  of 
abating,  a  weak  solution  of  nitrate  of  silver  may  be  employed : 

I^.  Argenti  nitratis,  gr.  iv; 

Aquae  destillatae,  5iv. 

In  the  stage  of  subsidence  the  injections  may  have  to  be  increased 
in  strength  ;  care,  however,  must  be  taken  to  discontinue  their  use  as 
soon  as  they  cause  smarting  in  the  urethra. 

Chronic  Urethritis. — After  every  other  symptom  of  gonorrhea 
has  disappeared  it  is  not  uncommon  to  have  the  urethral  discharge 
continue  for  an  indefinite  length  of  time.  To  such  chronic  discharge 
the  name  "  gleet  "  has  been  commonly  applied,  but  this  term  is  applic- 
able to  only  one  form  of  chronic  urethritis,  as  we  shall  presently  see. 
Cases  of  chronic  urethral  discharge  can  be  conveniently  divided  into 
three  classes : 


THE    GENITOURINARY  SYSTEM.  433 

1.  Catarrhal  Urethritis. — This  is  a  continuation  of  the  acute  form, 
and  in  many  instances  exists  more  in  the  patient's  mind  than  in  reality. 
It  is  often  little  more  than  a  moisture  of  the  urethra.  The  patient, 
worried  by  the  idea  that  he  has  not  recovered  from  the  discharge,  con- 
stantly "  strips "  the  urethra  to  see  what  can  be  pressed  out.  The 
only  time  he  succeeds  is  in  the  morning,  when  a  drop  or  two  of  clear 
albuminoid  liquid  can  be  expressed.  If  let  alone  this  discharge  ceases 
in  a  few  days  or  weeks,  and  it  is  best  to  allow  it  to  do  so. 

2.  Chronic  Gonorrhea. — After  inflammatory  symptoms  have  sub- 
sided along  the  course  of  the  urethra,  and  the  patient  has  passed 
through  all  the  stages  of  an  acute  attack,  one  spot  in  the  canal  may 
continue  to  give  trouble.  It  is  usually  the  seat  of  granulations  or  of 
ulceration,  and  the  most  common  situations  are  the  fossa  navicularis 
and  the  anterior  portion  of  the  membranous  urethra.  The  discharge 
is  milky  or  creamy  in  character,  an;d  can  be  pressed  out  of  the  meatus 
in  the  morning  or  during  the  day,  provided  the  trial  be  made  a  few 
hours  after  urinating.  The  diagnosis  of  the  part  of  the  urethra  which 
is  affected  is  arrived  at  in  three  ways : 

{ci)  "  Stripping "  the  urethra.  Pressure  of  the  penis  between  the 
thumb  and  finger  should  be  systematically  tried.  The  first  trial  should 
be  m.ade  a  little  behind  the  fossa  navicularis,  and  by  taking  an  inch  or 
so  at  a  time  the  point  is  at  last  reached  from  which  a  discharge  can  be 
passed  along  the  urethra  to  the  meatus. 

{8)  By  the  use  of  the  bulbous  bougie.  The  instrument,  several 
sizes  smaller  than  the  urethra,  is  passed  v^ery  slowly  and  any  painful 
point  carefully  noted.  Having  passed  beyond  the  sensitive  point,  the 
instrument  is  withdrawn,  and  the  discharge  which  has  been  brought 
away  by  the  shoulder  of  the  bulb  is  carefully  noted. 

(r)  By  the  urethroscope.  The  urethra  is  red  and  slightly  swollen, 
there  is  an  aching  sensation  felt  during  erection,  and  any  compression 
of  the  urethra  during  micturition  causes  pain. 

Treatment. — Having  located  the  granulated  spot,  it  is  necessar}^  to 
make  local  applications  to  its  surface.  About  6  to  8  minims  of  a  2 
to  10  per  cent,  solution  of  nitrate  of  silver  should  be  introduced  by 
means  of  a  prostatic  syringe  or  applied  with  an  applicator  through  the 
urethral  speculum.  For  a  day  or  two  the  irritation  caused  by  the  caus- 
tic will  increase  the  discharge.  After  this  injections  of  sulphate  of  cop- 
per, sulphocarbolate  of  zinc,  or  other  astringents  are  applied  in  the  same 
manner,  gradually  increasing  their  strength  as  the  conditions  require. 

3.  Gleet. — In  this  form  of  chronic  urethritis  the  discharge  is  of  a 
muco-purulent  character.  It  is  commonly  met  with  after  repeated 
attacks  of  gonorrhea  or  in  a  first  case  which  has  been  of  long  dura- 
tion. The  edges  of  the  meatus  are  found  in  the  morning  to  be  glued 
together  and  retaining  a  few  drops  of  a  whitish  fluid.  At  the  end  of 
micturition  there  is  usually  a  dribbling  of  urine.  This  indicates  a 
stricture  of  large  caliber. 

Treatment. — Gleet  so  commonly  depends  upon  commencing  stricture 
of  the  urethra  that  the  treatment  is  really  that  of  stricture.  By  exam- 
ination with  olive-pointed  bougies  the  position  and  caliber  of  the  stric- 
ture can  be  ascertained,  and  it  can  afterward  be  dilated  by  the  passage 
of  sounds.     Even  should  there  be  no  lessening  of  the  lumen  of  the 

28 


434  SURGICAL   DIAGNOSIS  AXD    TREATMENT. 

canal,  the  stimulation  of  the  mucous  membrane  by  the  pressure  of  a 
metallic  instrument  will  have  a  good  effect  in  setting  up  a  healthy 
action  and  arresting  the  discharge.  It  is  seldom  that  injections  are 
called  for  in  the  treatment  of  gleet. 

Stricture  of  the  Urethra. — By  stricture  is  meant  an  abnormal 
diminution  of  the  caliber  of  the  urethra  at  one  or  more  points  or 
throughout  its  whole  extent,  attended  with  changes  in  the  mucous, 
submucous,  and  muscular  structures  of  the  canal.  It  is  customary 
to  speak  of  three  varieties  of  stricture — spasmodic,  inflammatory,  and 
organic. 

Spasmodic  Stricture, — This  depends  upon  spasm  of  the  accelerator 
urina.'  and  compressor  urethras  muscles,  and  may  either  be  tempo- 
rary or  chronic.  It  is  brought  on  by  sexual  excess,  by  the  presence  of 
the  uric-  or  phosphatic-acid  diathesis,  by  intemperance,  by  exposure  to 
cold,  etc.  It  is  a  common  result  of  organic  stricture.  The  spasm 
occurs  usually  at  two  points — viz.  the  point  of  irritation  and  in  the 
musculo-membranous  urethra. 

Diagnosis. — The  diagnosis  is  not  difficult.  Retention  of  urine 
occurring  suddenly  in  a  person  whose  urethral  stream  was  previously 
of  fair  size,  and  as  suddenly  passing  off,  leaving  the  passage  as  free 
from  obstruction  as  before,  would  be  an  indication  of  spasmodic  stric- 
ture. A  bulbous  bougie  passed  into  the  canal  will  be  found  to  meet 
with  obstruction,  which  by  gentle  and  steady  pressure  may  be  over- 
come, or  the  instrument,  having  passed  the  obstructed  point,  may  be 
grasped  by  the  urethra  as  it  is  withdrawn. 

Treatment. — A  warm  bath  or  the  administration  of  morphia  or 
atropia  is  frequently  sufficient  to  overcome  the  spasm.  Failing  with 
these  measures,  a  soft-rubber  catheter  should  be  introduced  with  the 
greatest  gentleness,  and  this  should  be  done  while  the  patient  is  in  the 
bath,  or,  if  still  further  relaxation  be  needed,  he  can  be  placed  under 
an  anesthetic.  The  conditions  which  cause  the  stricture  should  be 
carefully  treated. 

Inflammatory  Stricture. — Inflammatory  and  spasmodic  strictures 
are  closely  allied.  It  is  doubtful  if  pure  spasmodic  stricture  exists 
without  the  presence  of  more  or  less  inflammatory  action,  and  it  is 
equally  doubtful  if  a  pure  inflammation  of  the  urethra  can  cause  reten- 
tion without  the  element  of  spasm.  Be  this  as  it  may,  it  is  a  clinical 
fact  that  in  acute  anterior  urethritis  obstruction,  amounting  in  some 
cases  to  retention,  is  a  frequent  occurrence. 

The  treat)nent  is  the  same  as  for  spasmodic  stricture,  combined  with 
the  proper  treatment  of  the  urethritis  which  is  the  exciting  cause. 

Organic  Stricture. — This  is  the  most  common  form  of  urethral 
stricture.  It  is  acquired  in  the  vast  majority  of  cases,  but  may  also 
be  congenital.  It  is  due  to  some  injury  of  the  urethra,  and  of  all 
causes  urethritis  is  by  far  the  most  common. 

The  cases  of  urethritis  most  liable  to  be  followed  by  stricture  are 
those  which  have  been  unusually  severe  or  have  had  a  protracted 
course. 

A  mild  urethritis  has  little  effect  upon  the  urethra,  simply  causing 
tenderness  of  its  surface  and  hypertrophy  of  its  papillae.  A  severe 
attack  or  one   which  is   prolonged  results   in   abundant   proliferation 


THE    GENITOURINARY  SYSTEM. 


435 


beneath  the  mucous  membrane,  and  the  formation  of  cicatricial  tissue, 
which  causes  constriction  of  the  canal.  This  may  occur  at  any  part 
of  the  urethra  except  one — the  prostatic  portion.  The  constriction  may 
be  very  limited,  forming  simply  a  ring,  as  if  a  cord  were  tied  around 
the  canal  at  that  point.  To  this  form  the  name  linear  stricture  has 
been  given.  When  the  strictured  portion  is  broader  the  name  annular 
is  applied,  and  when  it  involves  two  or  three  inches  of  the  canal  and  is 
crooked  and  irregular  it  is  called  a  tortuous  stricture.  The  most  fre- 
quent situation  is  in  front  of  the  triangular  ligament  for  a  distance  of 
one  inch.  Next  in  liability  is  the  portion  of  the  urethra  extending 
from  the  meatus  to  a  distance  of  about  two  inches,  and  the  least  liable 
is  the  middle  of  the  spongy  portion. 

Symptoms. — The  attention  of  the  patient  is  first  directed  toward  his 
condition  by  some  interference  with  urination.  The  stream  is  forked  or 
there  may  be  several  streams.  Simple  twisting  of  the  stream  is  of  little 
account,  as  this  may  be  due  to  the  shape  of  the  meatus.  At  the  end 
of  micturition  the  urine  dribbles  away,  owing  to  a  want  of  the  normal 
contractile  wave  of  the  accelerator  urinae  muscle.  After  a  time  the  stream 
becomes  small  and  there  may  be  complete  retention.  This,  however, 
is  not  due  to  total  closure  of  the  canal,  but  to  spasmodic  action.  Be- 
sides these  symptoms  indicating  obstruction,  there  is  generally  evidence 
of  inflammation,  as  a  gleety  discharge  noticed  especially  in  the  morn- 
ing or  after  exercise.  Inflammatory  thickening  may  be  felt  on  pal- 
pation of  the  urethra,  and  pain  may  be  present  to  a  greater  or  less 
degree. 

To  prove  the  existence  or  non-existence  of  stricture  an  examination 
with  instruments  is  necessary.  The  same  precautions  against  infection 
and  urethral  irritation  must  be  observed  as  in  catheterism  or  in  sound- 
ing the  bladder  for  stone.  The  best  instrument  is  Otis's  bougie  a  boule 
(Fig.  185)  or  Guyon's  bougie  exploratrice ;  the  former  has  an  unyield- 


FlG.  185. — Otis's  metallic  bougie  ^  boule. 


ing,  the  latter  a  flexible,  stem.     By  means  of  these  instruments  the 
urethra  can  be  explored  and  the  following  data  obtained : 

I.  The  position  of  the  stricture.  Before  using  the  instruments  a 
fair  idea  of  the  normal  size  of  the  individual  urethra  may  be  obtained 
by  the  method  recommended  by  Otis,  who  found  that  the  circumfer- 
ence of  the  flaccid  penis  bore  a  direct  relation  to  the  normal  size  of 
the  urethra.  A  table  based  upon  these  measurements  has  been  for- 
mulated, which  White  has  somewhat  extended.  The  measurements 
are  taken  at  the  middle  of  the  spongy  portion,  and  the  table  is  as 
follows : 


436  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

Circumference.  Size  of  sound. 

3  inches 26  to  28  French  scale. 

3X    "      28  to  30 

3>^    "       •    ■    •  30  to  32 

3^   " 32  to  34 

4  "       34  to  36 

This  table,  however,  must  not  be  looked  upon  a.s  strictly  accurate  : 
the  circumference  of  the  penis  is  subject  to  considerable  change,  and 
a  too  rigid  adherence  to  the  theory  would  result  in  the  passage  of  a 
sentence  of  stricture  on  almost  every  urethra.  If  the  meatus  is  ab- 
normally small,  it  must  be  incised  by  means  of  a  probe-pointed  knife. 

The  instrument  first  selected  should  be  of  moderate  size,  .say  15  to 
16  Fr. ;  if  this  can  be  passed  without  resistance,  No.  20  or  21  may  be 
tried.  If  you  succeed  in  passing  this  without  resistance,  you  may 
reasonably  infer  that  there  is  no  stricture. 

A  source  of  error  must  be  guarded  against  in  this  examination,  for 
it  frequently  happens  that  as  soon  as  the  bulb  of  the  instrument  passes 
the  fossa  navicularis  it  is  grasped  by  spasmodic  action  of  the  urethra 
and  firmly  held  ;  in  a  minute  or  two  the  muscular  fibers  become 
fatigued  and  the  bulb  can  be  passed  onward  without  resistance.  This 
spasm  may  occur  at  any  part  of  the  urethra,  and  is  most  apt  to  take 
place  in  patients  who  are  examined  for  the  first  time,  or  in  those  of 
nervous  temperament,  or  in  those  who  are  the  subjects  of  uric-acid 
diathesis. 

If  the  bulb  meet  with  sudden  resistance  (which  is  not  due  to  spasm 


Fig.  186. — Weir's  urethrometer. 


of  the  urethra)  and  cannot  be  passed  farther,  it  should  be  withdrawn, 
and  smaller  sizes  introduced  until  one  is  found  which  will  pass  the 
stricture  with  only  slight  resistance.  The  position  of  the  stricture  is 
now  carefully  noted. 

2.  The  length  of  the  stricture.  By  passing  the  bulb  beyond  the 
stricture,  and  then  withdrawing  it,  the  base  of  the  cone  can  be  felt  to 
catch  against  the  limit  of  the  stricture  farthest  from  the  meatus.  The 
nearest  point  has  already  been  ascertained,  and  the  distance  between 
the  two  will  represent  the  length  of  the  stricture.  In  many  cases  the 
resistance  of  the  stricture  can  be  felt  during  its  whole  length  as  the 
instrument  is  withdrawn. 

3.  The  degree  of  contraction  or  size  of  the  stricture.  This  can  be 
estimated  by  the  size  of  the  bulb  which  can  be  passed  with  a  slight 
resistance,  but  more  accurately  by  the  urethrometer  of  Otis,  Weir  (Fig. 
186),  or  Gross. 

4.  The  number  of  strictures.  This  may  be  difficult  to  determine  by 
the  aid  of  bougies,  but  the  urethrometer,  being  adjustable  to  the  caliber 
of  each  contraction,  is  the  proper  instrument  by  which  to  solve  the 
question. 


THE    GENITO-URINARY  SYSTEM.  437 

5.  The  condition  of  the  urethra  behind  the  stricture.  As  the  bougie 
is  withdrawn  it  carries  with  it  the  urethral  secretion  which  collects 
against  the  shoulder  of  the  bulb,  an  examination  of  which  will  afford 
some  idea  of  the  state  of  the  urethra. 

Classification  of  Organic  Strictures. — For  convenience  in  selecting  a 
mode  of  treatment  strictures  are  divided  according  to  the  degree  of 
contraction  into — 

1.  Those  of  lage  caliber.  No.  15  French  is  taken  as  the  limit;  any 
stricture  which  admits  a  larger  bougie  is  said  to  be  of  large  caliber. 

2.  Those  of  small  caliber  (less  than  No.  15  French). 

3.  Strictures  permeable  only  to  filiform  bougies. 

4.  Impassable  strictures. 

In  reference  to  the  situation,  the  following  classes  are  convenient : 

1.  At  the  meatus  or  fossa  navicularis. 

2.  In  the  pendulous  portion  of  the  urethra. 

3.  In  front  of  the  bulbo-membranous  junction. 

4.  At  or  behind  the  bulbo-membranous  junction. 

Treatment. — Before  considering  the  surgical  procedures  which  have 
been  devised  for  relief  of  stricture  attention  should  be  paid  to  some  points 
in  the  general  treatment  which  have  much  to  do  with  the  success  of 
operative  procedures.  The  patient  who  is  the  subject  of  a  stricture 
should  pay  the  closest  attention  to  sexual  and  genito-urinary  hygiene. 
Exposure  to  cold  should  be  avoided,  as  well  as  everything  approaching 
excess  in  eating  and  drinking.  When  cystitis  is  present,  as  is  frequently 
the  case,  this  condition  must  be  treated  and  remedies  used  w^iich  will 
prevent  decomposition  of  the  urine.  Quinin,  salol,  salicylate  of  soda, 
naphthalin,  boracic  acid,  and  creasote  are  all  useful  drugs  for  this  pur- 
pose. When  retention  of  urine  occurs  it  is  usually  due  to  spasm  of 
the  urethra  and  can  be  overcome  by  a  hot  bath. 

Operative  Treatment. — Many  modes  of  treatment  have  been  devised 
and  practised  for  the  relief  of  stricture,  a  large  proportion  of  which 
have  been  abandoned  as  barbarous,  useless,  and  unscientific.  The 
methods  now  in  use  and  meeting  with  more  or  less  general  approval 
are — i.  Gradual  dilatation;  2.  Continuous  dilatation  ;  3.  Urethrotomy 
and  dilatation  combined;  4.  Internal  urethrotomy;  5.  External 
urethrotomy  with  a  guide;  6.  External  urethrotomy  without  a  guide; 
7.  Electrolysis ;  8.  Excision  ;  9.    Subcutaneous  section. 

Let  us  now  consider  the  operative  treatment  suitable  for  the  various 
forms  of  organic  stricture  : 

1.  Stricture  of  the  MeatJis. — The  meatus  may  be  abnormally  con- 
tracted as  a  congenital  malformation  or  it  may  be  the  result  of  disease. 
In  either  case  the  treatment  consists  in  making  an  incision  with  a 
probe-pointed  knife,  the  blade  being  directed  downward  and  care  being 
taken  to  divide  the  fibrous  bands  which  are  the  cause  of  constriction. 
Bougies  should  be  passed  every  second  day  after  the  operation  to  keep 
the  orifice  dilated  until  healing  shall  have  taken  place. 

2.  Stricture  of  the  Pendulous  Portion. — Gradual  dilatation  should  be 
given  a  fair  trial.  Internal  urethrotomy  is  with  some  authors  the  favor- 
ite operation  for  strictures  in  this  portion  of  the  canal.  The  opera- 
tion is  almost  free  from  the  dangers  which  attend  its  use  in  the  deep 
urethra,  and  if  carried  out  under  aseptic  precautions  these  dangers  may 


438  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

practically  be  disregarded.  And  yet  discretion  is  necessary  in  a  choice 
of  method  even  here.  If  the  stricture  be  recent  and  soft,  gradual 
dilatation  may  give  good  results,  and  should  first  be  tried.  If  there  be 
gleet  or  the  stricture  be  unyielding,  urethrotomy  should  be  chosen, 
owing  to  its  freedom  from  danger  and  the  probability  of  its  effecting 
a  permanent  cure. 

Internal  urethrotomy  combined  with  dilatation  is  a  very  satisfactory 
method  of  treatment,  and  can  be  well  carried  out  by  the  aid  of  Otis's 
urethrotome.  Whatever  instrument  is  employed,  the  preparations  for 
the  operation  should  be  aseptic  in  every  detail.  The  urethra  should  be 
irrigated  with  a  bichlorid  solution  of  a  strength  of  i  :  10,000.  The 
hands  of  the  operator  and  the  instrument  should  be  as  carefully  dis- 
infected as  in  a  major  operation.  It  is  not  always  necessary  to  employ 
general  anesthesia,  as  a  solution  of  cocain  (4  per  cent.)  is  sufficient. 
The  incision  is  made  in  the  roof  of  the  urethra,  and  it  is  essential  that 
all  the  strictured  tissue  be  divided,  from  the  normal  urethra  behind  to 
the  normal  parts  in  front.  In  very  small  strictures  a  preliminary  incision 
may  be  necessary.  A  filiform  bougie  is  passed  through  the  stricture  to 
serve  as  a  guide;  over  this  a  Maisonneuve  urethrotome  (Fig.    187)  is 


\ 


Fig.  187. — Filiform  whalebone  bougies. 

passed  through  the  stricture,  and  an  incision  made  which  allows  the 
passage  of  a  dilating  urethrotome  and  division  of  the  stricture  from 
behind  forward. 

About  the  third  day  the  passage  of  sounds  should  be  commenced 
to  prevent  recontraction  during  the  healing  of  the  wound.  This 
should  be  repeated  once  or  twice  a  week  for  six  weeks  or  longer. 

Strictures  at  or  behind  the  Bulbo-mcinhranous  Jtinctioii. — These  are 
the  most  difficult  of  all  strictures  to  treat,  for  it  may  be  laid  down  as  an 
axiom  that  the  seriousness  of  stricture  increases  with  its  distance  from 
the  meatus.  When  of  large  caliber,  simple,  and  soft,  gradual  dilatation 
is  indicated.  Great  care  is  necessary  in  the  use  of  steel  instruments,  as 
the  urethral  mucous  membrane  is  soft  and  easily  lacerated.  In  treat- 
ment of  strictures  of  small  caliber  the  choice  lies  between  dilatation  and 
urethrotomy.  Good  results  are  obtained  by  using  continuous  dilata- 
tion for  twenty-four  or  forty-eight  hours,  and  gradual  dilatation  every 
second  day  thereafter.  Traumatic  strictures  in  this  situation  demand  ex- 
ternal urethrotomy  as  a  rule.  Sometimes  the  stricture  is  so  contracted  as 
to  render  it  impossible  to  pass  a  steel  sound  of  any  size.  Filiform  bougies 
are  employed  in  such  cases  wath  good  effect.  The  opening  may  not  be 
in  the  center  of  the  stricture,  but  at  some  part  of  its  circumference.  If 
the  filiform  bougie  cannot  be  passed,  withdraw  it  and  bend  the  point  of 
it  over  the  thumb-nail  to  an  angle  of  45°,  as  seen  in  Fig.  188.  By 
persevering  efforts  the  instrument  can  usually  be  made  to  enter  the 
stricture,  and  when  once  passed  it  should  be  left  there  for  twenty-four 
hours,  when  it  will  be  found  that  others  can  be  inserted  by  its  side. 


THE    GENITO-URINARY  SYSTEM.  439 

Having  succeeded  in  passing  a  filiform  bougie,  the  proceeding  will 
vary  according  to  circumstances.  First,  an  attempt  should  be  made  to 
pass  a  tunnelled  catheter  or  grooved  staff  over  the  filiform  into  the 
bladder,  after  which  gradual  dilatation  can  be  employed.  Or  the  fili- 
form can  be  used  as  a  guide  to  a  Maisonneuve  urethrotome,  and  inter- 
nal urethrotomy  performed,  followed  by  gradual  dilatation.  In  most 
cases,  however,  the  best  course  is  to  use  the  grooved  staff  as  a  guide 
and  perform  external  urethrotomy. 

In  spite  of  the  most  persevering  efforts  it  is  sometimes  impossible  to 
pass  ev^en  a  filiform  bougie.  A  stricture  of  this  kind  is  called  impassable. 
The  condition  is  attended  with  serious  consequences.  Retention  of 
urine  is  complete,  and  in  powerful  efforts  to  force  it  through  the  stricture 
the  urethra  may  give  way  and  extravasation  follow.  The  only  remedy 
is  perineal  section  or  external  urethrotomy  without  a  guide.  Extrav- 
asation of  urine  presents  symptoms  which  depend  upon  the  part  of  the 
urethra  which  has  suffered  the  urine  to  escape  through  its  walls.  In 
the  penile  urethra  the  swelling  will  be  found  to  extend  from  the  meatus 
to  the  scrotum,  and  will  be  most  marked  at  the  seat  of  rupture.     Rup- 


FlG.  188. — Maisonneuve's  urethrotome. 


ture  between  the  attachment  of  the  scrotum  and  the  anterior  part  of 
the  bulb  is  late  in  showing  itself  by  swelling ;  the  urine,  being  restricted 
by  the  deep  layer  of  the  superficial  fascia,  first  appears  in  the  scrotum, 
whence  it  escapes  between  the  pubic  spine  and  symphysis  and  reaches 
the  abdomen.  If  the  rupture  lies  between  the  two  layers  of  the  tri- 
angular ligament,  the  urine  will  be  imprisoned  until  suppuration  and 
sloughing  allow  it  to  break  through  and  appear  in  some  part  of  the 
perineum.  In  the  prostatic  urethra  extravasation  finds  its  way  along 
the  rectum  to  the  perineum  near  the  anus,  or,  passing  through  the 
pelvic  fascia,  it  may  spread  through  the  subperitoneal  connective  tissue. 
Another  result  of  extravasation  is  urethral  fistula.  The  urine  may 
escape  drop  by  drop  through  a  break  in  the  urethral  wall,  and  set  up 
suppuration,  resulting  in  an  abscess  which  opens  externally.  Accord- 
ing to  its  location  a  fistula  of  this  character  is  spoken  of  as  urethro- 
penile,  uretJiro-perineal,  and  itrethro-rectal.  There  is  little  or  no  dif- 
ficulty in  the  diagnosis,  as  the  escape  of  urine  through  a  fistulous 
opening  is  sufficient  evidence.  To  corroborate  this  sign  pass  a  steel 
sound  into  the  bladder  and  probe  the  fistula  from  its  external  opening. 
In  the  vast  majority  of  cases  urethral  fistulae  are  caused  by  strictures. 
The  treatment  consists  in  curing  the  stricture,  after  which  the  fistulous 
tract  is  laid  open  or  curetted.  During  the  healing  process  the  urine  is 
drawn  off  at  regular  intervals  or  a  catheter  is  retained  in  the  bladder. 


440 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


External  Urcthrotoiiy. — The  operation  of  incising  the  urethra  from 
without  is  indicated  in  complete  retention  due  to  stricture,  in  extravasa- 
tion of  urine,  and  in  several  forms  of  stricture  as  already  described. 
The  terms  external  urethrotomy  with  a  guide  and  external  urethrotomy 
without  a  guide  are  self-explanatory.  The  term  perineal  section  is  best 
reserved  for  those  cases  which  are  impermeable  to  all  instruments. 

Operation  ivith  a  Guide. — To  the  late  Prof  Syme  is  due  the  credit 
of  reviving  this  operation,  and  its  performance  has  been  greatly  facil- 
itated by  the  staff  which  he  invented  as  a  guide  (Fig.  189).     It  consists 


— Syme's  staff. 


of  a  sound  having  two  parts  of  different  diameters  ;  for  the  last  two 
and  a  half  inches  it  is  of  the  size  corresponding  to  No.  2  English,  and 
this  portion  is  grooved  on  its  convexity.  The  rest  of  the  staff  is  equal 
in  size  to  No.  10  English.  At  the  junction  of  the  two  parts  there  is  a 
shoulder  which  is  intended  to  rest  on  the  face  of  the  stricture.  The 
instrument  is  passed  carefully  along  the  urethra  and  the  slender  por- 
tion through  the  stricture,  the  finger  meanwhile  inserted  into  the  rec- 
tum to  guard  against  the  making  of  a  false  passage.  The  staff  is  then 
given  to  an  assistant,  who  holds  it  steadily  and  during  the  incision 
presses  the  convexity  of  the  instrument  downward  against  the  peri- 
neum. The  patient  is  placed  in  the  lithotomy  position.  The  operator 
inserts  his  left  fore  finger  into  the  rectum,  and,  cutting  exactly  in  the 
middle  line,  makes  an  incision  about  an  inch  in  front  of  the  anus  and 
cuts  down  upon  the  groove  in  the  staff.  Having  found  this,  he  uses  it 
as  a  guide  and  freely  divides  the  stricture.  Through  the  perineal  wound 
a  grooved  director  or  gorget  is  passed  into  the  bladder  and  the  staff 
removed.  The  next  step  is  to  pass  a  full-sized  catheter  by  the  urethra 
into  the  bladder,  the  grooved  director  or  gorget  (Fig.  190)  serving  as  a 


Fig.  190. — Teale's  probe-gorget. 


guide.  If  the  bladder  will  tolerate  it,  the  catheter  can  be  retained,  but 
this  is  not  necessary.  At  the  end  of  a  week  a  full-sized  bougie  a  boule 
should  be  passed,  keeping  close  to  the  roof  of  the  urethra.  This  is 
rendered  painless  by  the  injection  of  a  4  per  cent,  solution  of  cocain. 


THE    GENITO-URINARY  SYSTEM.  44 1 

and  should  be  repeated  every  second  day  for  the  first  week,  after  which 
the  intervals  may  be  gradually  lengthened. 

Operation  witJiout  a  Guide. — When  a  stricture  is  impermeable  even 
to  a  filiform  bougie,  the  operation  of  external  urethrotomy  without  a 
guide  is  indicated.  The  operation  of  Wheelhouse  of  Leeds  is  the  best. 
A  special  staff  is  employed  which  has  a  groove  throughout  its  entire 
length  except  the  last  half  inch  (Fig.  191).  The  operation  is  thus 
described  in  the  eminent  surgeon's  own  words  :  "  The  patient  is  placed 
in  the  lithotomy  position,  with  the  pelvis  a  little  elevated,  so  as  to  let 
the  light  fall  well  upon  it  and  into  the  wound  to  be  made.  The  staff 
is  to  be  introduced  with  the  groove  looking  toward  the  surface,  and 
brought  gently  into  contact  with  the  stricture  for  fear  of  tearing  the 
tissues  of  the  urethra  and  causing  it  to  leave  the  canal,  which  would 
mar  the  whole  after-proceedings,  which  depend  upon  the  urethra  being 
opened  a  quarter  of  an  inch  infron{  of  the  stricture.  Whilst  an  assist- 
ant holds  the  staff  in  this  position  an  incision  is  made  into  the  perineum, 
extending  from  opposite  the  point  of  reflection  of  the  superficial  peri- 
neal fascia  to  the  outer  edge  of  the  sphincter  ani.  The  tissues  of  the 
perineum  are  to  be  steadily  divided  until  the  urethra  is  reached.  This 
is  now  to  be  opened  in  the  groove  of  the  staff,  not  upon  the  point,  so 
as  certainly  to  secure  a  quarter  of  an  inch  of  healthy  tube  immediately  in 
front  of  the  stricture.  As  soon  as  the  urethra  is  opened  and  the  groove 
in  the  staff  fully  exposed,  the  edges  of  the  healthy  urethra  are  to  be 


Fig.  191. — Wheelhouse's  staff. 

seized  on  each  side  by  the  straight-bladed  nibbed  forceps  and  held 
apart.  The  staff  is  then  gently  withdrawn  until  the  button  point  appears 
in  the  wound.  It  is  then  to  be  turned  around  so  that  the  groove  may 
look  to  the  pubes,  and  the  button  may  be  hooked  into  the  upper  angle 
of  the  opened  urethra,  which  is  thus  held  stretched  open  at  three  points 
— at  two  by  the  forceps,  and  at  the  third  by  the  hook  of  the  staff. 
The  operator  looks  into  it  immediately  in  front  of  the  stricture,  inserts 
the  director  into  the  urethra,  and,  if  he  cannot  see  the  opening  of  the 
stricture,  which  is  often  possible,  generally  succeeds  in  very  quickly 
finding  it,  and  passes  the  point  onward  through  the  stricture  toward 
the  bladder.  The  stricture  is  sometimes  hidden  among  a  crop  of 
granulations  or  warty  growths,  in  the  midst  of  which  the  probe  point 
easily  finds  the  true  passage.  The  director  having  been  passed  on  into 
the  bladder  (its  entrance  into  which  is  clearly  demonstrated  by  the 
freedom  of  its  movements),  its  groove  is  turned  downward ;  the  whole 
length  of  the  stricture  is  carefully  and  deliberately  divided  on  its  under 
surface,  and  the  passage  is  then  cleared.  The  director  is  still  held  in 
the  same  position,  and  the  straight  probe-pointed  bistoury  is  run  along 
the  groove  to  ensure  complete  division  of  all  bands  or  other  obstruc- 
tions. These  being  thoroughly  cleared,  the  old  difficulty  of  directing 
the  point  of  a  catheter  through  the  divided  stricture  is  to  be  overcome. 
To  effect  this  the  point  of  the  probe-gorget  is  introduced  into  the 
groove  of  the  director,  and,  guided  by  it,  is  passed  onward  into  the 


442  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

bladder,  dilating  the  divided  stricture  and  forming  a  metallic  floor  along 
which  the  point  of  the  catheter  cannot  fail  to  pass  securely  into  the 
bladder.  The  short  catheter  is  now  passed  from  the  meatus  down  into 
the  wound ;  is  made  to  pass  once  or  twice  through  the  divided  urethra, 
where  it  can  be  seen  in  the  wound,  to  render  certain  that  no  obstructing 
bands  have  been  left  undivided,  and  is  then,  guided  by  the  probe- 
dilator,  passed  easily  and  certainly  along  the  posterior  part  of  the 
urethra  into  the  bladder.  The  gorget  is  now  withdrawn,  the  catheter 
fastened  in  the  urethra  and  allowed  to  remain  three  or  four  days,  the 
elastic  tube  conveying  the  urine  to  a  vessel  under  or  by  the  side  of  the 
bed.  After  three  or  four  days  the  catheter  is  removed,  and  is  then 
passed  daily  or  every  second  or  third  day  according  to  circumstances 
until  the  wound  in  the  perineum  is  healed,  and  after  the  parts  have  be- 
come consolidated  it  requires  to  be  passed  still  from  time  to  time  to 
prevent  recontraction." 

Great  difficulty  is  sometimes  experienced  in  finding  the  proximal 
end  of  the  urethra,  especially  in  traumatic  strictures.  If  the  bladder 
contain  considerable  urine  and  pressure  be  made  over  it,  a  jet  of  the 
liquid  may  reveal  the  opening  of  the  urethra.  The  same  result  may 
be  obtained  by  bimanual  palpation,  with  the  fingers  of  one  hand  over 
the  bladder  and  those  of  the  other  hand  in  the  rectum.  Failing  in  this, 
the  parts  should  be  douched  with  hot  water,  when  the  urethra  will 
become  prominent  by  its  being  paler  than  the  other  tissues.  Every 
effort  to  find  the  urethra  having  proved  futile,  the  best  way  out  of  the 
difficulty  is  to  perform  a  suprapubic  cystotomy  and  make  retrograde 
dilatation. 

CJioicc  of  Operation. — Gradual  dilatation  is  the  simplest  and  safest 
operation,  and  is  generally  successful.  It  may  fail  in  tight  strictures 
close  to  the  meatus,  and  then  internal  urethrotomy  should  be  resorted 
to.  Tight  strictures  of  the  bulbo-membranous  region  may  resist  all 
efforts  at  gradual  dilatation ;  external  urethrotomy  is  then  to  be 
chosen,  especially  if  the  stricture  is  of  traumatic  origin.  Impassable 
strictures  leave  no  choice,  and  must  be  treated  by  external  urethrotomy. 

Urinary  Pouches. — A  stricture  or  the  presence  in  the  urethra  of 
a  calculus  sometimes  causes  a  pouching  or  rupture  of  the  urethra 
behind  the  obstruction,  and  the  formation  of  a  reservoir  which  holds  a 
quantity  of  urine  that  is  not  expelled  in  micturition.  This  condition 
may  be  mistaken  for  urethral  abscess,  the  preliminary  to  urethral  fistula 
already  mentioned. 

Symptoms. — Urinary  pouches  appear  as  round  or  ovoid  tumors 
along  the  course  of  the  urethra.  There  is  absence  of  pain  and  redness, 
but  there  is  fluctuation.  The  swelling  becomes  more  tense  and  promi- 
nent during  the  act  of  micturition,  after  which  it  is  more  relaxed,  but 
does  not  disappear.  The  patient,  having  learned  by  experience  that 
the  tumor  can  be  prev^ented  from  filling,  makes  pressure  with  the 
fingers  of  his  right  hand  while  he  holds  the  penis  in  the  left  during 
urination.  The  urine  which  remains  in  the  pouch  in  spite  of  this  or 
other  precautions  dribbles  away  later  on,  soiling  the  clothing  of  the 
patient  and  causing  great  annoyance.  In  some  cases  the  urethra  is 
merely  dilated,  and  then  the  urine  contained  in  the  pouch  is  always 
normal ;  in  another  class  of  cases  there  is  a  breach  of  continuity  in 


THE    GENITO-URINARY  SYSTEM.  443 

the  urethral  wall ;  a  pouch  forms  in  the  same  manner,  but  the  urine  is 
likely  to  contain  pus  or  blood,  and  frequently  ends  in  urinary  fistula. 

Treatment. — When  the  urethra  is  simply  dilated  the  whole  treatment 
must  be  directed  against  the  obstruction  which  is  the  cause  of  the 
pouch.  A  calculus  if  present  must  be  removed  or  a  stricture  remedied. 
When  there  is  perforation  of  the  urethra  it  is  sometimes  sufficient  to 
retain  a  catheter  and  use  mild  compression  externally.  When  there  is 
an  abscess  it  should  be  opened,  and  a  catheter  kept  in  the  urethra  to 
prevent  the  formation  of  a  fistula. 

VI.    INJURIES  AND  DISEASES  OF  THE  MALE  GENERATIVE  ORGANS. 

Diseases   and   Malformations   of   the    Penis. 

The  meatus,  instead  of  opening  in  its  normal  position,  in  very  rare 
cases  is  found  to  open  at  the  side  or  in  the  dorsum  of  the  penis.  In 
absence  of  the  bladder  the  ureters  have  been  found  to  empty  into  the 
urethra,  and  the  rectum  has  in  very  rare  instances  been  known  to  have 
a   similar  outlet. 

These  malformations  are  of  little  practical  value,  but  there  are 
two  others  which  require  more  extensive  notice — viz.  hypospadias  and 
epispadias. 

Hypospadias  is  a  malformation  the  distinctive  feature  of  which  is  an 
absence  of  the  lower  wall  of  the  urethra,  so  that  the  canal  opens  on  the 
under  surface  of  the  penis.  The  opening  may  be  in  the  glans  or  in  the 
spongy  portion,  or  the  urine  may  be  expelled  at  the  scroto-perineal 
junction.  When  the  hypospadic  opening  is  at  the  scroto-perineal 
junction  there  is  a  fissure  in  the  scrotum,  giving  it  the  appearance  of 
the  external  genitalia  of  the  female ;  the  penis  is  bound  down  to  the 
fissure  and  may  be  very  much  atrophied.  In  the  penile  variety  the 
opening  maybe  at  any  point  on  the  floor  of  the  pendulous  urethra,  and 
an  almost  constant  complication  is  a  downward  curvature  of  the  penis. 
An  opening  within  an  inch  of  the  normal  position  of  the  meatus  may 
be  attended  with  little  inconvenience,  and  requires,  as  a  rule,- no  treat- 
ment, but  a  penile,  scrotal,  or  perineal  hypospadia  is  one  of  the  most 
distressing  of  abnormalities  and  requires   operative  interference. 

Of  the  diagnosis  there  is  little  to  be  said,  as  the  condition  is  self- 
evident. 

Treatment. — Several  operations  have  been  devised,  but  the  method 
of  Duplay  is  the  only  one  that  has  met  with  success.  It  consists  of 
three  stages  : 

1.  Straightening  the  Penis. — This  is  done  by  making  a  transverse 
incision  of  the  ridge  which  unites  the  hypospadic  opening  to  the  glans, 
the  incision  being  carried  to  a  depth  which  will  secure  complete 
straightening  of  the  penis  (Fig.  192,  A).  In  this  incision  it  may  be 
necessary  to  go  deeply  into  the  corpora  cavernosa,  but  this  can  be  done 
without  risk.  When  the  organ  is  straight  or  but  slightly  curved  this 
step  of  the  operation  is  not  necessary. 

2.  TJie  Formation  of  a  Nezv  Canal  from  the  Meatus  to  the  Hypospadic 
Opening. — The  first  point  to  demand  attention  is  the  formation  of  a 
meatus.    The  position  of  this  opening  is  indicated  by  a  depression  in  the 


444 


SURGICAL    DIAGNOSIS  AND    TREATMENT. 


glans  penis.  The  two  lips  of  this  depression  are  vivified  as  in  F'ig.  192, 
B.  Between  them  is  placed  the  tip  of  a  catheter,  and  over  this  the 
edges  of  the  freshened  surfaces  are  secured  by  several  catgut  sutures. 
If  the  depression  is  too  shallow,  more  room  can  be  gained  by  making 


A  B 

Fig.  192. — Duplay's  operation  for  hypospadias  (Duplay  and  Reclus). 


two  small  lateral  incisions,  a,  a',  or  a  single  median  incision  in  the  sub- 
stance of  the  glans.  Next  comes  the  formation  of  the  new  canal. 
Along  the  lower  surface  of  the  penis  on  each  side  of  the  middle  line 
two  incisions  are  made  from  the  corona  glandis  to  within  a  quarter  of 
an  inch  of  the  hypospadic  opening  (Fig.  193).  The  internal  lip  at  a  d 
is  dissected  up  and  turned  inward  over  the 
catheter,  but  not  entirely  covering  it.  The  ex- 
ternal lip,  r,  d,  c',  d' ,  is  freely  dissected  so  as  to 
separate  the  skin  from  the  subjacent  tissues, 
and  so  as  to  allow  the  skin  of  the  sides  of  the 
penis  to  be  drawn  toward  the  middle  line.  The 
cutaneous  surface  of  the  lips  at  a'  b'  are  turned 
toward  the  cavity  of  the  canal,  and  their  raw 
surfaces  toward  the  outside  and  covered  by  the 
raw  surfaces  of  the  outer  flaps.  The  edges  of 
the  flaps  are  united  in  the  middle  line  by  quilled 
sutures  of  silver  wire,  silkworm  gut,  or  silk,  and 
fastened  with  perforated  shot. 
3.  Jimctiojiof  tlic  Tivo  Portions  of  the  Canal. — This  consists  in  closing 
the  fistulous  opening  which  still  remains  at  the  hypospadic  orifice  by 
freshening  the  edges  and  bringing  them  together  by  quilled  sutures 
over  the  catheter.     A  retained  catheter  is  employed  to  carry  off  the 


Fig.  193.  —  Transverse 
section  of  the  penis  after 
operation  :  S,  the  new  ure- 
thra (Duplay  and  Reclus). 


THE    GENITO-URINARY  SYSTEM.  445 

urine  during  the  healing  process.  The  whole  process  of  the  cure  of 
hypospadia  is  long  and  tedious.  Three,  four,  or  five  operations  may  be 
necessary,  and  the  treatment  may  extend  over  six  or  eight  months. 

Hpispadias  is  a  much  rarer  abnormality,  and  consists  in  a  de- 
ficiency of  the  upper  wall  of  the  urethra.  The  operation  for  its  cure  is 
similar  to  that  just  described. 

Phimosis  is  characterized  by  an  unnaturally  elongated  condition 
of  the  prepuce,  with  so  small  an  opening  that  it  is  impossible  to  uncover 
the  glans.  The  condition  may  be  congenital  or  acquired.  The  acquired 
form  has  already  been  described  as  a  complication  of  balanitis  and 
balano-posthitis.  The  congenital  variety  is  important  on  account  of  the 
continual  irritation  kept  up  by  it,  leading  in  extreme  cases  to  chorea, 
•epilepsy,  and  other  nervous  affections.  The  glans  is  often  adherent  to 
the  prepuce  in  whole  or  in  part ;  the  preputial  orifice  is  usually  small, 
sometimes  little  larger  than  a  pinhole,  and  during  micturition  the  pre- 
puce become  distended  with  urine.  The  secretion  collects  inside,  and 
the  danger  of  infection  is  greatly  increased  should  the  patient  be 
exposed  to  venereal  diseases. 

Treatment. — When  a  corona  glandis  cannot  be  completely  exposed 
without  difficulty  circumcision  should  be  performed.  The  parts  having 
been  carefully  disinfected,  the  prepuce  is  drawn  well  forward  and  grasped 
by  a  pair  of  forceps  in  front  of  the  anterior  extremity  of  the  glans.  The 
blades  of  the  forceps  should  be  an  inch  and  a  half  in  length,  so  as  to 
grasp  the  whole  width  of  the  prepuce.  With  ordinary  care  there  is  no 
risk  of  wounding  the  glans,  although  this  has  happened  in  the  hands 
of  incompetent  operators.  With  a  sharp  knife  the  foreskin  in  front  of 
the  forceps  is  removed.  The  prepuce  is  now  allowed  to  retract,  when 
it  will  be  found  that  while  the  skin  recedes  to  the  corona  or  behind  it 
the  mucous  membrane  forms  a  hood  over  the  glans.  This  membrane 
is  slit  in  the  middle  line  up  to  the  corona,  and  then  cut  off  all  around 
at  a  distance  of  one-sixteenth  of  an  inch  from  the  point  of  reflection. 
This  will  be  found  to  follow  the  line  of  the  corona.  The  frenum  should 
be  spared  unless  there  is  marked  hypertrophy  at  that  point.  The  edges 
of  the  skin  and  mucous  membrane  should  be  approximated  by  inter- 
rupted catgut  sutures.  The  most  convenient  dressing  is  a  thin  layer  of 
absorbent  cotton  covering  the  incision  and  sealed  over  with  iodoform- 
ized  collodion.  The  end  of  the  penis  can  be  protected  from  irritation 
by  absorbent  cotton  and  a  T-bandage. 

Paraphimosis. — Should  the  glans  be  forced  through  a  prepuce 
too  narrow  to  admit  it,  constriction  is  sure  to  follow.  The  glans 
becomes  swollen,  congested,  and  edematous ;  the  orifice  of  the  pre- 
puce forms  a  constricting  ring,  while  the  part  of  the  prepuce  behind 
falls  forward  like  an  edematous  collar.  Unless  relieved,  this  condition 
ends  in  ulceration  and  sloughing.  The  glans  should  be  pushed  back 
in  the  manner  described  under  Phimosis  due  to  Gonorrhea.  Failing  in 
this,  a  director  should  be  passed  beneath  the  constricting  ring  and  the 
constriction  divided. 

Carcinoma  of  the  Penis. — Epithelioma  of  the  squamous  variety 
is  the  only  form  found  upon  this  organ.  It  begins  as  a  warty  growth 
upon  the  glans  or  the  inner  surface  of  the  prepuce,  and  it  is  said  that 
phimosis  is  a  predisposing  cause.    The  wart  soon  breaks  down  and  forms 


446  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

ail  ulcer  with  very  hard  margins.  The  disease  rapidly  spreads  by  infil- 
tration of  the  surrounding  parts,  and  sooner  or  later  the  corpora  caver- 
nosa, the  glans,  and,  secondarily,  the  lymphatics  of  the  groin,  become 
involved.  The  only  disease  with  which  it  is  liable  to  be  confounded  is 
syphilis.  The  ulceration  of  epithelioma  is  recognized  by  attention  to 
the  following  points : 

1.  It  is  a  chronic  ulcer,  with  an  irregular  hard  base  and  a  foul, 
watery,  or  bloody  discharge. 

2.  The  growth  infiltrates  the  tissues  of  the  penis,  and  at  the  same 
time  grows  from  its  surface. 

3.  Antisyphilitic  treatment  has  no  effect  upon  the  disease. 

4.  The  inguinal  glands  become  involved  sooner  or  later, 

5.  Microscopic  examination  shows  cancerous  elements. 
TrcatDioit. — The  only  remedy  is  amputation,  and  in  view  of  the 

rapidity  of  the  growth  this  treatment  should  be  resorted  to  at  an  early 
period.  The  operation  was  formerly  done  by  a  simple  sweep  of  the 
knife,  or  at  most  by  the  formation  of  a  flap  of  the  skin  to  cover 
the  surface  of  the  wound.  This  method  was  followed  by  stricture 
of  the  orifice  of  the  urethra  and  frequently  by  recurrence  of  the 
disease. 

The  best  results  are  obtained  by  amputation  of  the  entire  penis,  and 
the  operation  of  Pearce  Gould  is  now  generally  adopted.  The  method 
of  its  performance  is  thus  described  by  Treves : 

Operation. — "  The  patient  having  been  placed  in  the  lithotomy  posi- 
tion, the  skin  of  the  scrotum  is  incised  along  the  whole  length  of  the 
raphe.  With  the  finger  and  the  handle  of  the  scalpel  the  two  halves 
of  the  scrotum  are  then  separated  quite  down  to  the  corpus  spongiosum. 
A  full-sized  metal  catheter  is  now  passed  as  far  as  the  triangular  ligament^ 
and  the  knife  is  inserted  transversely  between  the  corpora  cavernosa  and 
the  corpus  spongiosum. 

"  The  catheter  having  been  withdrawn,  the  urethra  is  cut  across. 
The  deep  end  of  the  urethra  is  then  detached  from  the  penis  quite  back 
to  the  triangular  ligament.  An  incision  is  next  made  around  the  root 
of  the  penis  continuous  with  that  in  the  median  line ;  the  suspensory 
ligament  is  divided  and  the  penis  separated,  except  at  the  attachment 
of  the  crura.  The  knife  is  now  laid  aside,  and  with  a  stout  periosteal 
elevator  each  crus  is  detached  from  the  pubic  arch.  This  step  of  the 
operation  involves  some  time,  on  account  of  the  very  firm  union  of  the 
parts  to  be  severed.  Four  arteries — the  two  arteries  of  the  corpora 
cavernosa  and  the  two  dorsal  arteries — require  ligature. 

"  The  corpus  spongiosum  is  slit  up  for  about  half  an  inch,  and  the 
edges  of  the  cut  stitched  to  the  back  part  of  the  incision  in  the 
scrotum. 

"  The  scrotal  incision  is  closed  by  sutures,  and  a  drainage-tube  is  so 
placed  in  the  deep  part  of  the  wound  that  its  ends  can  be  brought  out 
in  front  and  behind.     No  catheter  is  retained  in  the  urethra. 

"  In  Gould's  case — the  operation  was  performed  for  epithelioma  in 
a  man  aged  seventy-three — there  was  no  complaint  of  pain  after  the 
operation.  The  temperature  reached  the  normal  line  on  the  fourth 
day,  and  on  the  sixth  day  the  patient  had  regained  complete  control 
over  the  bladder.    The  skin-wound  healed  by  first  intention,  the  deeper 


THE    GENITO-URINARY  SYSTEM.  447 

wound  by  granulation.     The  parts  were  completely  healed  in  forty-six 
days." 

Diseases  of  the  Scrotum. 

Bdema  and  Inflammation. — Owing  to  the  looseness  of  the 
tissues  which  form  the  scrotum,  swelling  may  occur  rapidly  and  attain 
an  enormous  size.  Edema  is  recognized  by  its  doughy  feel,  by  its 
pitting  on  pressure,  by  the  disappearance  of  the  normal  scrotal  folds, 
and  by  the  glossy  character  of  the  skin.  It  is  commonly  the  result  of 
dropsy  in  the  lower  extremities  due  to  cardiac  or  kidney  disease,  but  it 
may  follow  any  acute  inflammation  of  the  part.  Inflammation  of  the 
scrotum  is  common,  but,  like  inflammation  in  other  loose  tissues,  such 
as  the  eyelid,  the  swelling  is  out  of  proportion  to  the  other  symptoms, 
and  need  give  no  great  uneasiness,  as  it  is  likely  to  disappear  as  rapidly 
as  it  came  on.  The  most  serious  form  of  scrotal  inflammation  is  that 
due  to  extravasation  of  urine.  This  is  about  the  only  form  which  is 
really  dangerous,  and  it  demands  the  most  prompt  and  vigorous  treat- 
ment of  the  extravasation.  Eczema  and  the  irritation  of  dribbling  urine 
are  also  common  causes  of  mild  forms  of  inflammation. 

Kpithelioma  of  the  scrotum  differs  little  from  this  form  of  carci- 
noma in  other  situations.  In  the  scrotum,  however,  it  is  almost  invari- 
ably due  to  a  definite  cause — the  irritation  of  soot,  hence  the  name 
"  chimney  sweep's  cancer."  It  appears  as  a  wart  with  hard  edges 
raised  above  the  surrounding  skin  and  irregular  in  shape.  It  spreads 
from  the  margin  and  ulcerates  in  the  center.  In  the  early  stages  it  is 
confined  to  the  skin  and  is  freely  movable,  but  later  it  becomes  attached 
to  the  deeper  tissues,  spreads  to  the  glands  of  the  groin,  and  involves 
the  penis.  Removal  of  the  growth  by  operation  is  very  satisfactory  if 
resorted  to  in  time.  It  would  be  wisdom  to  remove  any  warty  growth 
with  hard  edges  and  showing  a  disposition  to  spread.  Even  after  the 
disease  has  invaded  the  glands  removal  is  followed  by  a  good  percentage 
of  recoveries. 

Elephantiasis  of  the  scrotum  is  common  in  some  Eastern  coun- 
tries as  elephantiasis  Arabian.  It  is  characterized  by  enormous  hyper- 
trophy of  the  skin  and  subcutaneous  cellular  tissue.  It  is  often 
associated  with  repeated  attacks  of  inflammation,  such  as  attend 
urinary  fistula,  or  it  may  depend  upon  lymphatic  destruction  and 
inflammation.  From  the  scrotum  it  may  extend  to  the  penis,  but 
never  to  the  testicles. 

Swellings  of  the  Scrotum. — There  is  no  part  of  the  body  in 
which  so  great  a  variety  of  swellings  is  met  with  as  in  the  scrotum. 
In  most  of  the  cases  presenting  themselves  for  examination  the  patients 
consult  the  surgeon  for  the  purpose  of  ascertaining  the  nature  of  some 
enlargement  of  these  parts.  A  systematic  examination  should  cover 
the  following  ground : 

A.  The  swelling  is  confined  to  the  scrotum.  It  is  either  edema,  ele- 
phantiasis, epithelioma,  or  other  tumor.  Edema  is  associated  with 
dropsy  of  the  lower  extremities,  but  it  may  be  a  result  of  extravasation 
of  urine.  Elephantiasis  is  a  tropical  disease,  or  it  may  be  the  result  of 
repeated  attacks  of  inflammation.  Tumors  found  in  connection  with 
the  scrotum  are  lipoma  and  epithelioma ;  other  growths  are  rare. 


448  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

B.  The  swelling  is  connected  with  the  testicles  or  their  coverings. 
It  must  be  one  of  the  following :  orchitis,  malignant  disease,  benign 
tumor,  hydrocele,  hematocele. 

C.  The  swelling  is  connected  with  the  spermatic  cord.  It  is  either 
an  inflammation,  a  hydrocele  of  the  cord,  a  varicocele,  or  a  tumor. 

Orchitis,  or  Inflammation  of  the  Testicle. — This  is  easily  rec- 
ognized by  pain,  tenderness  to  touch,  and  its  association  with  trau- 
matism, gonorrhea,  tuberculosis,  or  syphilis.  It  is  convenient  to  divide 
orchitis  into  two  varieties,  acute  and  chronic.  Acute  orchitis  is  gen- 
erally the  result  of  traumatism,  but  may  also  be  an  extension  of  the 
inHammatory  process  from  the  epididymis  or  it  may  be  metastatic,  as 
in  mumps.  The  pain  is  acute  and  the  organ  is  very  sensitive  to  the 
slightest  touch.  Swelling  comes  on  rapidly,  and  the  skin  over  the 
affected  gland  is  red  and  glistening.  Suppuration  is  not  an  uncom- 
mon result,  especially  in  patients  of  low  vitality. 

Treatment. — The  pain  is  kept  up  and  greatly  aggravated  by  the 
weight  of  the  testicle ;  hence  the  first  point  in  treatment  is  to  support 
the  scrotum  and  its  contents  by  the  use  of  a  suspensory  bandage  or  by 
a  small  pillow  placed  beneath  the  parts  while  the  patient  lies  on  his 
back.  A  brisk  purgative  often  produces  an  immediate  effect  upon  an 
acute  orchitis,  and  should  come  in  as  a  part  of  the  routine  treatment. 
In  the  early  stages  of  the  inflammatory  process  cold  applications  afford 
relief,  especially  in  the  form  of  lead-and-opium  lotion ;  later  the  same 
application  as  warm  as  can  be  conveniently  borne  will  be  more  suc- 
cessful. When  there  is  great  tension  and  the  case  resists  the  above 
remedies,  an  incision  should  be  made  into  the  tunica  vaginalis. 

Chronic  orchitis  is  generally  a  complication  of  syphilis,  and  espe- 
cially if  confined  to  the  body  of  the  testicle.  In  gonorrhea  and  tuber- 
culosis the  swelling  is  likely  to  be  confined  to  the  epididymis.  There 
is  one  character  w'hich  distinguishes  the  syphilitic  testicle,  and  that  is 
its  weight.  It  is  remarkably  heavy  as  compared  with  the  normal 
organ  or  with  the  weight  of  the  organ  under  any  other  diseased  condi- 
tion. Chronic  orchitis  of  any  kind  is  likely  to  produce  atrophy  of  the 
testicle,  or  if  suppuration  begins  the  organ  soon  becomes  riddled  with 
sinuses  and  is  finally  destroyed.  The  diagnosis  of  chronic  orchitis  is 
very  plain,  but  the  variety  of  the  inflammation — that  is  to  say,  whether 
it  is  syphilitic,  tubercular,  gouty,  or  malignant — is  very  necessary  to 
determine. 

Syphilitic  testicle  has  an  even,  smooth  surface  when  the  deposit  is 
distributed  through  the  whole  of  the  fibrous  tissue  of  the  gland.  The 
organ  retains  its  normal  shape,  but  it  is  enlarged,  hard,  and  heavy. 
When  the  condition  is  due  to  a  single  gumma  or  several  separate  gum- 
mata  the  swelling  is  uneven  and  nodular.  It  comes  on  slowly,  is  free 
from  pain,  and  generally  attacks  both  testicles  simultaneously.  A  his- 
tory of  other  manifestations  of  syphilis  and  the  readiness  with  which 
the  enlargement  responds  to  antisyphilitic  treatment  need  leave  no 
doubt  in  the  minds  of  the  examiners.  The  form  of  testicular  enlarge- 
ment with  which  it  is  most  likely  to  be  confounded  is  the  gouty,  but 
the  previous  history  will  usually  be  clear  enough  to  differentiate  them. 

Treatment. — lodid  of  potassium  acts  speedily  upon  the  swelling  up 
to  a  certain  point,  when  improvement  ceases  and  a  hard  mass  remains 


THE    GENITO-URINARY  SYSTEM.  449 

as  a  permanent  deposit.  Mercury  cannot  be  applied  to  the  scrotum, 
but  has  a  very  good  effect  when  rubbed  into  the  skin  of  the  inside  of  the 
thigh.  It  can  be  given  internally  in  the  form  of  the  bichlorid.  When 
every  other  form  of  treatment  has  failed  and  the  testicle  is  disorganized, 
it  should  be  removed  by  castration. 

Tubercular  Orchitis. — In  many  cases  tuberculosis  in  the  testicle  is 
a  manifestation  of  constitutional  disease.  The  enlargement  begins  usu- 
ally as  a  hard  nodule  at  the  back  of  the  testicle  or  in  the  epididymis. 
Like  syphilitic  orchitis,  it  is  frequently  bilateral.  In  the  advanced 
stages  caseous  degeneration  causes  a  breaking  down  of  the  tissues,  and 
should  the  infection  of  suppuration  be  superadded  the  whole  organ  may 
become  riddled  with  abscesses. 

Treatment. — The  treatment  must  be  carried  out  on  the  principles 
which  govern  the  treatment  of  tuberculosis  elsewhere.  Residence  at 
the  seaside  or  a  long  sea-voyage  is  especially  to  be  recommended. 
When  the  disease  is  confined  to  one  testicle  and  has  advanced  to  the 
destructive  stage,  the  organ  being  riddled  with  sinuses,  castration  is 
advisable,  care  being  taken  to  divide  the  vas  deferens  as  high  up  as 
possible. 

Gouty  orchitis  is  exceedingly  rare,  and  closely  resembles  the 
syphilitic  form.  It  is  not  always  easy  to  trace  its  connection  with  the 
gouty  diathesis.  The  enlargement  is  confined  to  the  testicle  itself,  the 
epididymis  remaining  unaffected.  Like  other  manifestations  of  gout, 
this  form  of  orchitis  is  painful,  and  in  some  cases  the  inflammation  is 
severe. 

Malignant  Disease  of  the  Testicle. — Carcinoma  of  the  testicle 
appears  as  the  encephaloid  or  soft  variety.  A  peculiarity  of  cancer 
in  this  situation  is  that  it  attacks  men  comparatively  young,  the  major- 
ity of  cases  being  between  twenty  and  forty.  It  is  usually  confined 
to  one  testicle,  and  appears  as  one  or  more  small  hard  nodules  in  the 
body  of  the  testis,  the  epididymis  becoming  involved  later.  At  first  the 
surface  of  the  tumor  is  smooth  and  even,  but  as  the  growth  increases 
and  breaks  through  the  tunica  albuginea  it  becomes  uneven,  with  hard 
and  soft  areas  alternating.  The  progress  of  the  disease  is  characterized 
by  the  horrible  features  which  are  inseparable  from  cancer.  The 
growth  is  steady  and  may  attain  an  enormous  size ;  large  veins 
traverse  its  surface  ;  the  skin  becomes  adherent,  just  as  it  does  in  cancer 
of  the  female  breast ;  it  ulcerates,  and  a  fungous  mass  breaks  forth 
covered  with  unhealthy  granulations,  foul  smelling,  and  throwing  off 
sloughs  of  connective  tissue  and  even  parts  of  the  gland  itself  This 
fungous  mass  is  very  vascular,  bleeding  on  the  slightest  irritation,  and 
sometimes  threatening  life  by  profuse  hemorrhage.  The  epididymis  has 
suffered  early,  the  cord  falls  a  victim  later  on,  and  the  destroyer  passes 
on  to  the  glands  and  to  distant  organs  till  the  life  of  the  patient  goes 
out  in  exhaustion. 

Sarcoma  may  occur  at  any  age,  not  even  the  unborn  infant  being 
exempt.  The  most  of  the  cases  are  below  ten  or  between  thirty  and 
forty.  Following  a  law  of  sarcoma,  the  round-celled  variety  is  the 
most  malignant,  and  sometimes  it  is  an  impossibility  to  distinguish  it 
from  soft  cancer ;  but  practically  it  matters  little,  for  both  are  terribly 
malignant,  the  same  treatment   is  demanded,  and,  unfortunately,  the 

29 


450  SURGICAL   DIAGNOSIS  AXD    TREATMENT. 

resources  of  our  art  arc  set  at  defiance  by  one  as  well  as  by  the 
other. 

In  the  other  forms  of  sarcoma,  the  spindle-celled  and  the  t^iant- 
celled,  cysts  are  frequently  met  with,  and  sometimes  cartilaginous 
formations.  Sir  Astley  Cooper  called  these  cysts  "  hydrated  testicles." 
They  must  be  distinguished  from  hydrocele  and  hematocele,  and  gen- 
erally this  can  be  done  without  difficulty,  for  the  cystic  testicle  is 
heavier  than  a  hydrocele  and  is  opaque.  Hematocele  is  more  apt  to 
cause  confusion,  but  if  a  trocar  be  inserted  the  hematocele  will  be 
found  to  contain  blood  more  or  less  altered,  while  the  cystic  growth 
produces  little  or  no  blood.  Cartilaginous  growths  must  always  be 
looked  upon  with  suspicion ;  theoretically  they  are  benign,  clinically 
they  are  almost  sure  to  be  associated  with  sarcoma.  The  features  that 
distinguish  sarcomatous  from  other  enlargements  of  the  testicle,  accord- 
ing to  Jacobson,  are — i.  Continuously  progressive  solid  enlargement 
without  inflammation ;  2.  Unequal  resistance  of  the  swelling  at  differ- 
ent parts  ;  3.  Entire  absence  of  translucency ;  4.  Tendency  to  become 
adherent;  5.  Increasing  aches  or  painfulness ;  6.  Enlargement  of  the 
cord  and,  a  fortiori,  of  the  lumbar  glands. 

Treatment. — No  hope  can  be  held  out  to  a  patient  suffering  either 
from  carcinoma  or  sarcoma  of  the  testicle,  except  by  early  removal  of 
the  gland.  Even  then  the  prospect  of  permanent  cure  is  not  bright. 
The  operation,  however,  is  attended  with  but  slight  danger,  and,  as  it 
is  almost  sure  to  prolong  life  and  lessen  suffering,  its  performance 
should  not  be  delayed. 

Operatio}i. — Castration  is  performed  as  follows  :  The  parts  having 
been  shaved  and  disinfected,  the  skin  is  steadied  by  the  thumb  and 
fingers  of  the  left  hand,  and  an  incision  made  from  the  external  abdom- 
inal ring  along  the  course  of  the  cord  and  down  to  the  lower  end  of 
the  scrotum.  This  incision,  however,  is  not  advisable  when  the  skin 
is  adherent  to  the  adjacent  parts.  An  eliptical  incision  meeting  above 
and  below  the  adherent  portion  is  the  best  under  such  circumstances. 
Layer  by  layer  is  divided ;  all  are  freely  movable  until  the  tunica  vagi- 
nalis is  reached,  when  it  will  be  found  to  be  immovable.  The  first 
layer,  then,  which  is  immovable  is  the  tunica  vaginalis.  This  should 
be  opened  for  diagnostic  reasons,  and  if  necessary  to  reduce  the  size 
of  the  tumor.  The  cord  having  been  separated  from  surrounding  tis- 
sues and  the  tumor  shelled  out  by  the  finger,  aided  here  and  there  by 
touches  of  the  knife,  moderate  traction  is  made  upon  the  cord,  and  it 
is  then  tied  off  This  can  be  done  in  several  ways:  i.  The  cord  is 
grasped  with  a  clamp,  divided  below  the  instrument,  and  the  vessels 
tied  separately.  This  is  the  safest  and  best  method.  2.  The  whole 
cord  may  be  tied  eii  masse  by  a  stout  chromicized  catgut  or  silk  liga- 
ture, the  ends  cut  off  short  and  allowed  to  slip  up  into  the  canal.  3. 
A  double  ligature  may  be  passed  through  the  substance  of  the  cord 
and  the  two  halves  tied  separately  (Jacobson).  Some  operators  place 
a  rubber  drainage-tube  in  the  inguinal  canal  in  contact  with  the  stump 
of  the  retracted  cord,  but  this  is  unnecessary.  The  utmost  care  should 
be  taken  to  ensure  complete  hemostasis  before  losing  sight  of  the  cord 
or  closing  the  wound,  for  even  the  oozing  of  a  small  vessel  may  cause 
troublesome  hemorrhage  for  days  after  the  operation.     In  closing  the 


THE    GENITO-URINARY  SYSTEM. 


451 


wound  a  blunt  hook  placed  in  each  angle  should  be  made  to  stretch 
the  edges  of  the  skin  and  prevent  their  turning  inward  by  the  action 
of  the  dartos. 

Benign  Tumors. — These  may  be  cystic  or  solid.  Hydatid  and 
dermoid  cysts  are  difficult  to  diagnosticate  except  by  removal  and 
examination  of  their  contained  fluids.  Cystic  adenomata  grow  slowly, 
are  free  from  pain,  and  rarely  appear  before  puberty.  The  solid  tumors 
are  fibromata  and  enchondromata.  While  cysts  present  a  nodular 
appearance,  these  solid  growths  are  smooth.  The  testicle  is  hard  and 
heavy%  thus  simulating  the  syphilitic  testicle. 

Abnormalities  of  the  Testicles. — The  testicle  sometimes  fails  to 
reach  the  scrotum,  and  remains  at  some  point  in  the  inguinal  canal,  in 
the  abdominal  cavity,  or  just  outside  the  external  abdominal  ring.  This 
abnormality  is  known  as  retained  testicle.  Its  chief  inconvenience  con- 
sists in  the  liability  of  the  organ  to  inflammator}'  attacks.  It  sometimes, 
when  complicated  with  hernia,  prevents  the  wearing  of  a  truss,  and  is 
probably  a  predisposing  cause  of  malignant  disease. 

Treatment. — Unless  the  retained  organ  gives  trouble  it  is  best  to  let 
it  alone,  no  operation  for  placing  it  in  its  proper  position  havang  so  far 
proved  satisfactory.  When  it  is  producing  trouble  and  the  other  organ 
is  normal,  castration  is  the  proper  course. 

Absence  of  both  testes  is  rare,  but  it  is  not  very  uncommon  to  find 
an  individual  who  only  possesses  a  single  gland. 

Hydrocele  is  a  term  applied  to  any  collection  of  fluid  about  the 


Fig.  194. — Hydrocele  (Keen  and  White). 

testicle  or  spermatic  cord,  but,  as  a  rule,  this  fluid  is  confined  in  the 
tunica  vaginalis.  It  occurs  at  any  age,  and  may  vary  in  size  from  a 
barely  perceptible  enlargement  of  the  scrotum  to  a  tumor  of  enormous 
dimensions.  Traumatism,  violent  muscular  effort,  and  relaxation  of  the 
scrotum  by  residence  in  tropical  climates  have  been  assigned  as  causes. 

In  the  congenital  form  of  the  disease  the  peritoneal  cavity  commu- 
nicates with  the  tunica  vaginalis,  thus  allowing  the  abdominal  serum  to 
trickle  down  along  the  cord  to  the  testicles. 

The  diagnosis  of  hydrocele  is  generally  easy.  The  swelling  is  first 
observed  at  the  lower  end  of  the  scrotum ;  it  is  smooth,  tense,  fluctu- 


452  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

ating,  and  increases  slowly.  It  is  free  from  pain  and  other  inflamma- 
tory symptoms.  All  these  symptoms  are  not  sufficient  to  differentiate 
hydrocele  from  other  enlargements  in  the  scrotum,  but  there  is  one 
sign  which  is  pathognomonic,  and  that  is  the  translucency  of  the 
tumor.  If  the  patient  be  examined  in  a  darkened  room  and  the 
scrotal  swelling  held  between  the  surgeon's  eye  and  a  lighted  candle, 
the  tumor  will  allow  the  light  to  pass  through  it ;  all  other  scrotal 
swellings  are  opaque.  This  test,  however,  is  interfered  with  if  the 
tunic  is  greatly  thickened,  as  is  sometimes  the  case,  or  if  the  serous 
fluid  is  mixed  with  blood.  The  aspirating  needle  should  be  employed 
in  cases  of  doubt. 

Inexperienced  examiners  are  liable  to  mistake  hernia  for  hydrocele, 
and  vice  versa,  and  the  writer  has  more  than  once  been  consulted 
because  a  truss  for  inguinal  hernia  could  not  be  made  to  fit  over  a 
hydrocele.  With  ordinary  care  and  a  study  of  the  symptoms  this 
error  need  not  occur.  Except  when  strangulated  a  hernia  has  an 
impulse  on  coughing,  and  the  swelling  can  be  traced  up  to  and  into 
the  inguinal  canal.  Both  hernia  and  hydrocele  may  be  present,  but 
even  then  an  impulse  can  be  felt  when  the  hernial  portion  of  the 
swelling  is  grasped  between  the  thumb  and  finger. 

Hydrocele  of  the  cord  is  recognized  by  its  sausage  shape  and  by  its 
being  connected  with  the  cord. 

Treatment. — Congenital  hydrocele  may  be  cured  by  a  truss,  which 
prevents  the  flow  of  serum  from  the  abdominal  cavity  into  the  tunica 
vaginalis ;  failing  in  this,  the  neck  of  the  sac  should  be  ligated. 

The  treatment  of  other  forms  is  palliative  or  radical.  Palliative 
treatment  consists  in  tapping  the  tunic  as  often  as  it  becomes  over-dis- 
tended. The  radical  operation  aims  to  obliterate  the  sac  by  the  injec- 
tion of  iodin  or  carbolic  acid  or  by  incision.  Tapping  is  thus  performed  : 
The  position  of  the  testicle  having  been  ascertained,  the  skin  and  trocar 
disinfected,  the  left  hand  grasps  the  tumor  so  as  to  render  the  skin  tense. 
The  trocar  is  grasped  by  the  thumb  and  finger  of  the  right  hand  so  as 
to  form  a  guard  which  will  prevent  the  instrument  being  thrust  in  too 
far,  and  is  then  by  a  quick  movement  made  to  perforate  the  scrotum. 
If  the  object  is  simply  palliative,  the  trocar  is  withdrawn  and  the  fluid 
allowed  to  escape  through  the  cannula.  In  the  radical  operation  the 
fluid  is  withdrawn,  and  then  the  cavity  is  injected  with  five  or  six  drams 
of  the  undiluted  tincture  of  iodin,  which  should  be  caused  to  permeate 
every  part  of  the  sac  by  shaking  up  the  scrotum  or  gently  kneading  it. 
The  opening  made  by  the  trocar  is  closed  by  iodoformized  collodion. 
Instead  of  tincture  of  iodin,  some  surgeons  use  from  five  to  ten  drops 
of  pure  carbolic  acid  in  sufficient  water  to  keep  it  in  a  liquid  state.  It 
produces  less  irritation  than  iodin. 

For  the  first  two  days  after  injection  the  swelling  may  return  to  its 
former  size  and  the  parts  become  violently  inflamed,  but  this  soon 
subsides  and  a  cure  may  be  expected  at  the  end  of  three  or  four  weeks. 

Incision  is  an  effectual  method  of  dealing  with  hydrocele.  It  con- 
sists in  laying  open  the  tunica  vaginalis  for  a  distance  of  about  an  inch 
and  a  half  and  stitching  the  edges  of  the  tunic  to  the  skin.  A  drainage- 
tube  is  inserted  or  the  cavity  packed  with  iodoform  gauze  and  allowed 
to  heal  by  the  open  method. 


THE    GENITO-URINARY  SYSTEM.  453 

Hematocele  is  a  condition  in  which  the  tunica  vaginahs  is  distended 
with  blood.  It  sometimes  occurs  after  tapping  a  hydrocele  or  it  may 
follow  a  traumatism  or  inflammation  of  the  tunic.  The  tumor  is  ovoid 
in  shape,  but  broader  at  its  most  dependent  part.  It  does  not  fluctuate, 
but  is  hard,  opaque,  and  heavy.  Difficulty  may  arise  in  distinguishing 
it  from  an  old  hydrocele  with  thickened  walls,  and  from  tumor  of  the 
testicle.  In  some  cases  this  point  can  only  be  decided  by  exploration 
or  incision. 

Traumatic  hematocele  is  easily  recognized  by  the  rapidity  with  which 
the  symptoms  develop,  a  tumor  of  considerable  size  forming  in  a  few 
minutes  or  a  few  hours  at  most. 

Treatment. — In  acute  traumatic  cases  the  patient  should  lie  in  bed 
with  the  scrotum  supported  on  pillows,  while  cold  and  moderate  pres- 
sure are  employed  to  check  the  extravasation  of  blood.  Failing  to  get 
rid  of  the  hematocele  in  this  manner,  and  especially  if  the  case  is  of  long 
standing,  the  proper  course  is  to  lay  the  part  open  by  an  incision,  turn 
out  the  clots  and  fibrinous  deposits,  examine  the  testicle,  and  remove  it 
if  diseased  or  disorganized,  pack  the  cavity  with  iodoformized  gauze,  and 
allow  it  to  heal  by  granulation. 

Inflammation  of  the  spermatic  cord  very  rarely  occurs  as  a  pri- 
mary affection,  but  as  a  sequel  of  gonorrheal  or  syphilitic  orchitis  it  is 
not  uncommon.  The  cord  is  hard,  tender  to  the  touch,  and  painful, 
especially  when  the  weight  of  the  testicle  drags  upon  it.  The  consti- 
tutional symptoms  are  often  well  marked,  but  it  is  seldom  that  the  dis- 
ease proceeds  to  suppuration.  The  treatment  is  that  of  other  local 
inflammations,  with  attention  to  the  specific  disease  which  may  be 
acting  as  a  cause. 

Hydrocele  of  the  Cord. — Two  varieties  are  recognized — diffused 
and  encysted,  the  latter  being  the  more  common. 

Diffused  Hydrocele. — This  variety  arises  as  follows  : 

In  its  descent  to  the  scrotum  the  testicle  carries  with  it  a  double 
layer  of  peritoneum,  which  goes  to  form  the  serous  sac  lining  the 
inguinal  canal :  one  layer  is  in  contact  with  the  spermatic  cord  and  the 
tunica  albuginea,  the  other  with  the  inner  surface  of  the  cremaster 
muscle  and  the  scrotum.  Between  these  two  layers,  as  they  surround 
the  testicle,  is  the  space  known  as  the  tunica  vaginalis.  In  normal 
development  the  space  between  the  two  layers  becomes  obliterated  at 
the  lower  end  of  the  inguinal  canal,  so  that  the  two  become  blended 
into  one  as  they  invest  the  spermatic  cord.  Sometimes,  however,  this 
blending  does  not  take  place,  and  the  layers  remain  separate  in  the 
inguinal  canal.  If  serum  accumulates  in  this  space,  it  forms  a  tumor 
resembling  a  sausage  and  extending  from  the  internal  abdominal 
ring  almost  to  the  testicle.  It  is  readily  recognized  by  fluctuation 
and  by  its  shape.  When  the  patient  stands  up,  the  fluid,  gravitating 
to  the  lower  end  of  the  canal,  gives  the  tumor  a  pyriform  appearance. 
The  same  effect  can  be  produced  by  pressure  downward  along  the 
course  of  the  cord.  The  similarity  of  this  tumor  to  omental  hernia  is 
likely  to  mislead  the  unwary,  especially  when  it  has  an  impulse  on 
coughing,  as  is  sometimes  the  case.  Care  should  be  taken  to  note  the 
change  in  shape  brought  about  by  the  position  of  the  patient,  the  fluc- 
tuation at  the  lower  end  of  the  tumor,  and  its  bulging  when  pressure  is 


4S4 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


made  downward  aloni:^  tlic  course  of  the  cord.    It  must  also  be  remem- 
bered that  both  h\-drocele  and  omental  hernia  ma)'  coexist. 

Trcatiiioit. — The  tumor  can  be  aspirated  and  injected  with  iodin  as 
an   ordinary  h}'drocele. 

Encysted  Hydrocele. — When  the  two  layers  of  the  covering  of  the 
cord  are  blended  in  several  places,  the  intervening  spaces  remaining 
sejiarated,  and  when  these  spaces  become  distended  with  serum,  the 
condition  is  known  as  encysted  h)'drocele  (Fig.  195).  While  the  patient 
stands  erect  the  symptoms  resemble  those  of  the 
diffuse  form  of  hydrocele,  but  on  assuming  the 
recumbent  posture  the  tumor  disappears  slowly. 
This  distinguishes  it  from  hernia,  for  the  latter 
goes  up  quickly  and  has  its  peculiar  gurgle. 

Treatment. — This  form  can  usually  be  cured 
by  wearing  a  truss.  In  infants  simple  puncture 
is  often  sufficient.  Failing  in  this,  a  silk  thread 
should  be  passed  through  the  tumor,  loosely 
knotted,  and  left  to  act  as  a  seton  for  forty-eight 
hours.  This  operation  should  be  carried  out  with 
aseptic  care  and  the  part  covered  with  an  aseptic 
dressing.  A  sufficient  amount  of  inflammation 
is  thus  established  to  cause  obliteration  of  the 
sac. 

Varicocele. — The  term  varicocele  is  applied 
to  a  dilated  and  tortuous  condition  of  the  veins 
of  the  spermatic  cord.  Two  groups  of  veins 
exist  in  the  cord — the  anterior,  accompanying  the 
spermatic  artery  and  forming  the  pampiniform 
plexus  ;  it  is  this  group  which  is  most  commonly 
involved  in  varicocele.  The  posterior  group  attends  the  spermatic 
artery  and  surrounds  the  vas  deferens.  Occasionally  this  group  also 
becomes  varicose.  Varicocele  occurs  almost  universally  on  the  left 
side,  and  for  this  clinical  fact  the  following  reasons  have  been  assigned  : 
I.  The  left  vein  as  it  enters  the  renal  vein  has  no  valve.  2.  It  is  longer 
than  the  corresponding  vein  on  the  right  side.  3.  It  enters  the  renal 
vein  at  a  right  angle  to  the  current  of  the  blood.  4.  It  passes  behind 
the  sigmoid  flexure  and  is  subject  to  occasional  pressure. 

Symptoms. — No  great  skill  is  required  for  the  diagnosis  of  varicocele. 
The  scrotum  contains  a  soft  mass  resembling  a  bunch  of  worms. 
There  is  usually  no  acute  pain,  but  a  dull  aching  is  commonly  present. 
The  scrotum  hangs  down  loosely  and  is  of  a  purplish  color,  and  the 
tortuosities  of  the  veins  can  be  seen  through  the  skin.  Perspiration  on 
that  side  of  the  scrotum  is  usually  present.  The  testicle  is  generally 
soft  and  sometimes  atrophied.  Like  many  other  disorders  of  the 
sexual  system,  varicocele  is  apt  to  produce  a  form  of  melancholia, 
and  many  patients  erroneously  get  the  idea  that  they  are  impotent. 
Treatment. — Palliative  treatment  consists  in  wearing  a  suspensory 
bandage,  and  nearly  every  patient  who  consults  a  surgeon  for  varico- 
cele comes  clothed  in  this  regalia.  For  mild  cases  attended  with  no 
pain  or  inconvenience  this  is  satisfactory,  but  when  pain  and  constant 
aching  are  present,  when  the  testicle  is  gradually  wasting  away  or  the 


Fig.    195. — Encysted    hy 
drocele. 


INJURIES  AND  DISEASES   OF  THE  HEAD.  455 

patient's  mental  condition  threatening  to  prove  serious,  something  of  a 
more  radical  nature  is  demanded.  Two  operations  are  in  common  use, 
either  of  which  can  be  recommended. 

I  shall  mention  first  the  operation  of  incision  of  the  veins,  with 
shortening  of  that  side  of  the  scrotum,  as  it  is  the  most  thorough  and 
satisfactory  when  properly  performed. 

In  any  operation  upon  the  cord  the  vas  deferens  must  be  located 
and  kept  out  of  harm's  way.  It  lies  at  the  posterior  and  inner  aspect 
of  the  cord,  and  is  recognized  by  its  tough,  leathery  feel.  It  has  a  per- 
sistent way  of  slipping  out  of  the  grasp  of  the  thumb  and  finger. 

Operation. — The  parts  having  been  shaved  and  thoroughly  disin- 
fected, an  assistant  locates  the  vas  deferens  and  keeps  it  out  of  the  way, 
while  at  the  same  time  he  makes  tense  the  skin  of  the  scrotum.  The 
operator  then  makes  an  incision  for  about  two  inches  over  the  most 
prominent  part  of  the  varicocele.  The  group  of  veins  is  exposed,  but 
not  separated  from  one  another,  and  at  the  lower  end  of  the  incision  an 
aneurysmal  needle  is  passed  beneath  the  group,  carrying  a  short  catgut 
ligature.  This  is  securely  tied  and  one  end  cut  short.  A  ligature  is 
applied  in  a  similar  manner  at  the  upper  angle,  and  one  end  cut  short 
as  before.  The  portion  of  the  plexus  lying  between  the  ligatures  is 
then  removed  by  scissors.  The  two  long  ends  of  the  ligatures  are 
next  tied  together,  thus  shortening  the  cord  and  raising  up  that  side 
of  the  scrotum.  The  incision  in  the  skin  is  closed  with  a  continuous 
catgut  suture  and  a  proper  dressing  applied. 

The  second  operation  is  that  of  Keyes.  The  vas  deferens  being 
kept  well  in  the  background,  a  needle  armed  with  stout  aseptic  silk 
is  passed  through  the  scrotum  between  the  vas  and  the  group  of  veins, 
and  left  in  position  ;  a  second  needle,  threaded  with  the  free  end  of  the 
same  thread,  is  entered  beside  the  first  needle,  and,  after  passing  through 
the  skin  and  dartos,  is  carefully  made  to  surround  the  veins  and  emerge 
beside  the  first  needle  at  the  opposite  side  of  the  scrotum.  Both 
needles  are  now  drawn  through,  thus  placing  a  loop  around  the  veins. 
The  silk  is  securely  tied  in  a  single  square  knot  and  the  ends  cut  short. 
The  two  layers  of  scrotal  skin  are  now  separated,  and  the  knot  slips 
within  the  dartos,  where  it  becomes  encapsulated.  The  small  openings 
made  by  the  needles  can  be  sealed  with  iodoformized  collodion  :  the 
patient  should  remain  in  bed  one  day  and  keep  in-doors  for  four  or  five 
days  longer. 


CHAPTER   VIII. 
INJURIES   AND    DISEASES   OF  THE   HEAD. 

I.   CEREBRAL  TOPOGRAPHY. 

Injuries  of  the  scalp  and  of  the  bones  of  the  cranium  would  have 
no  special  importance  were  it  not  for  the  danger  of  brain-complications, 
which  danger  is  ever  present  in  such  traumatisms.  A  wound  of  the 
scalp  heals  as  readily  as  a  wound  of  the  soft  parts  in  any  other  portion 


456  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

of  the  body,  but  unless  the  greatest  care  be  taken  in  its  treatment  such 
a  wound  may  become  infected,  and  the  infection  may  thence  be  carried 
to  the  brain  or  its  membranes.  A  fracture  of  the  skull,  as  far  as  the 
bone  itself  is  concerned,  is  unimportant,  for  union  readily  takes  place, 
and  there  is  not  so  much  thickening  at  the  point  of  union  as  is  usually 
found  in  repair  of  other  bones.  But  fractures  of  the  skull  are  exceed- 
ingly grave  injuries,  from  the  fact  that  the  fragments  almost  invariably 
cause  direct  compression  of  the  brain  or  produce  hemorrhage,  which  is 
a  source  of  danger  no  less  grave.  Before  proceeding  to  the  injuries  of 
the  head  the  brain  itself  must  claim  our  attention. 

An  organ  so  essential  to  the  economy,  so  highly  developed,  so 
exquisitely  delicate  and  sensitive,  must  of  necessity  be  well  protected. 
The  skull  is  the  strong  casket  which  contains  this  precious  jewel,  and 
to  this  end  it  is  admirably  adapted.  It  is  formed  of  strong  bones,  with 
additional  strength  where  most  exposed  to  violence,  presenting  a  con- 
vex surface  from  which  blows  glance  and  missiles  are  deflected.  Within 
the  cranium  cushions  of  cerebro-spinal  fluid  support  the  brain  and  break 
the  force  of  shocks  and  jars  to  which  it  would  otherwise  be  exposed. 

The  strong  and  unyielding  skull,  however,  is,  under  certain  condi- 
tions, a  source  of  danger  to  the  brain.  When  inflammation  attacks  the 
organ  or  its  membranes,  when  pus  accumulates  or  blood  is  extrav- 
asated,  there  is  no  room  for  expansion  ;  brain-pressure  soon  follows, 
showing  its  presence  by  paralysis  or  by  other  manifestations  of  func- 
tions impaired  or  entirely  destroyed.  Dangers  from  this  source  are 
not  only  immediate,  but  remote,  assuming  at  more  or  less  distant 
periods  the  form  of  epilepsy  or  insanity. 

Although  the  functions  of  the  various  regions  of  the  brain  are  still 
imperfectly  understood,  a  wonderful  amount  of  light  has  been  thrown 
upon  this  subject  in  recent  years.  For  our  knowledge  in  this  interest- 
ing field  of  study  we  are  indebted  to  Broca  in  France,  Fritsch,  Goltz, 
and  Hitzig  in  Germany,  and  Ferrier  and  Horsley  in  England.  Their 
investigations  have  demonstrated  the  fact  that  different  parts  of  the 
brain  preside  over  different  motions  of  the  body.  The  functions  of 
certain  areas  are  pretty  definitely  understood,  while  other  parts  are 
still  a  terra  incognita. 

There  are  five  areas  whose  functions  have  been  demonstrated ;  they 
are — i.  The  sensori-motor  area;  2.  The  area  which  presides  over 
speech;  3.  The  area  of  vision;  4.  The  area  of  hearing;  5.  The  area 
of  sensations  of  smell  and  taste. 

I.  The  Sensori-motor  Area. — To  comprehend  the  limits  of 
these  areas  let  us  examine  the  outer  surface  of  the  left  hemisphere 
of  the  brain  (Fig.    196). 

The  cerebrum  is  divided  into  two  hemispheres,  the  right  and  the 
left.  The  gray  covering  or  cortex  of  each  hemisphere  presents  three 
surfaces — the  lateral,  the  median,  and  the  basal.  The  most  interesting 
to  surgeons  is  the  lateral  surface,  in  the  study  of  which  we  recognize 
certain  fissures,  lobes,  and  convolutions.  It  has  four  lobes — the  frontal, 
parietal,  occipital,  and  temporal.  Each  lobe  is  furrowed  by  certain 
fissures  or  sulci,  and  between  these  lie  the  convolutions  or  gyri. 

The  frontal  lobe  (F)  contains  two  sulci,  the  superior  and  inferior 
(/i  and  f).     It  also  contains  the  following  convolutions  :  the  superior. 


INJURIES  AND  DISEASES   OF  THE  HEAD. 


457 


median,  and  inferior  frontal  {F^,  F^,  F^),  and  the  ascending  frontal  or 
anterior  central  convolutions  (A). 

The  Parietal  Lobe. — Between  the  frontal  and  the  parietal  lobe  is  the 
fissure  of  Rolando  (<:-).  This  lobe  contains  the  posterior  central  con- 
volution {B)  and  the  superior  and  inferior  parietal  lobules  {P^,  P.^.  The 
inferior  parietal  lobule  is  subdivided  into  the  supramarginal  convolution 
at  the  posterior  limit  of  the  fissure  of  Sylvius,  and  the  angular  gyrus 
bending  round  the  posterior  limit  of  the  temporo-sphenoidal  fissure  {P^}. 

The  temporal  lobe  lies  between  the  fissure  of  Sylvius  and  the  cere- 
bellum.   It  contains  the  first  and  second  temporal  fissures  and  the  first, 


Fig.  196.— Outer  surface  of  the  left  hemisphere  (Ecker) :  A,  anterior  central  or  ascending 
frontal  convolution  ;  B,  posterior  central  or  ascending  parietal  convolution  ;  c,  sulcus  centralis 
or  fissure  of  Rolando ;  cw,  termination  of  the  calloso-marginal  fissure  :  F,  frontal  lobe  ;  F\, 
superior,  F-i,  middle,  and  Fz.  inferior  frontal  convolutions ;  /i,  superior,  and  f-i,  inferior  frontal 
sulcus  ;/3,  sulcus  praecentralis  ;  ip,  sulcus  intraparietalis  ;  O,  occipital  lobe  ;  0\,  first,  02,  second, 
O3,  third  occipital  convolutions;  t^i,  sulcus  occipitalis  transversus ;  (12,  sulcus  occipitalis  longi- 
tudinalis  inferior;  P,  parietal  lobe;  po,  parieto-occipital  fissure;  P\,  superior  parietal  or  pos- 
tero-parietal  lobule;  P-i,  inferior  parietal  lobule— viz.  Pu  gyrus  supramarginalis ;  P-i  ,  gyrus 
angularis;  6',  fissure  of  Sylvius;  S ,  horizontal,  S" ,  ascending  ramus  of  the  same;  T,  temporo- 
sphenoidal  lobe;  T\,  first,  Ti,  second,  Ts,  third  temporo-sphenoidal  convolutions;  /i,  first,  h, 
second  temporo-sphenoidal  fissures. 

second,  and  third  temporal  convolutions,  or  the  superior,  middle,  and 
inferior  convolutions,  as  they  are  sometimes  called. 

At  first  thought  one  might  expect  to  find  that  the  boundaries  of 
these  areas  would  follow  the  lines  of  the  lobes  and  convolutions,  but 
such  is  not  the  case.  It  is  interesting  to  note  that  the  relative  positions 
of  the  motor  centers  correspond  with  the  relative  positions  of  the  parts 
over  which  they  preside.  Instead  of  inscribing  the  names  of  the  parts 
controlled,  I  have  had  drawn  upon  the  brain  itself  the  figure  of  the 
body  (see  Fig.  197),  showing  at  a  glance  the  whole  field  of  cerebral 
localization  and  adding  new  interest  to  this  absorbing  study.  It  looks 
as  if  the  Almighty  had  traced  his  own  image  upon  the  masterpiece  of 
his  handiwork,  and  recorded  the  crowning  triumph  of  creation  in  a 
language  which  we  are  just  beginning  to  learn,  and  in  characters 
which  we  hope  soon  to  decipher. 

The  first  landmark  to  which  we  must  direct  our  attention  is  the 


458 


SURGICAL    DIAGNOSIS  AND    TREATMENT. 


fissure  of  Rolando  (r).  It  may  be  compared  to  a  ravine,  one  bank  of 
which  is  formed  by  the  anterior  central  convolution,  the  other  by  the 
posterior  central  convolution.  In  the  cortex  of  this  area  and  in  the 
adjacent  cortex  in  front  and  behind  is  located  the  sensori-motor  area. 
The  left  hemisphere  of  the  brain  presides  over  the  right  side  of  the 
body,  and  the  right  hemisphere  over  the  left  side.  Roughly  speaking, 
the  upper  one-third  of  the  sensori-motor  area  controls  motions  of  the 
lower  extremity  of  the  opposite  side,  the  middle  third  controls  the 
upper  extremity  of  the  opposite  side,  and  the  lower  third  presides  over 
the  movements  of  the  face  (see  Fig.  197). 

To  be  more  precise  :  let  us  first  examine  the  upper  third  or  the  area 
of  the  leg.     The  fissure  has  in  front  of  it  the  anterior  central  convolu- 


FlG.  197. — Cerebral  localization. 

tion,  and  posterior  to  it  is  the  posterior  central  convolution.  Proceed- 
ing from  before  backward,  we  find  that  the  anterior  central  convolution 
controls  motions  of  the  thigh,  and  the  posterior  central  convolution  con- 
trols movements  of  the  leg,  foot,  and  toes.  In  front  of  the  thigh  district 
is  supposed  to  be  the  region  which  controls  movements  of  the  trunk 
(Fig.  197). 

In  the  middle  third  of  the  fissure  of  Rolando  and  in  the  convolutions 
on  each  side  of  it  is  the  arm  center.  Well  forward  in  the  posterior 
part  of  the  second  frontal  convolution  is  the  area  which  governs  the 
movements  of  the  head  and  eyes.  Proceeding  backward,  we  find  the 
area  for  the  shoulder  and  elbow  in  the  anterior  central  convolution, 
and,  crossing  over  the  fissure,  we  come  upon  the  district  of  the  wrist, 
fingers,  and  thumb  in  the  posterior  central  convolution. 

In  the  lower  third  of  the  fissure  and  the  anterior  and  posterior  cen- 
tral convolutions  is  the  area  which  governs  the  face,  tongue,  pharynx, 
and  larjaix.  The  upper  and  anterior  portion  of  this  area  controls  the 
eyebrows    and  cheeks,  the    lower  and  forward  part    the  tongue  and 


INJURIES  AND  DISEASES   OF   THE  HEAD.  459 

larynx,  and  the  posterior  part  the  mouth,  pharynx,  and  platysma 
myoides. 

When  we  say  that  a  given  area  controls  a  certain  motion  or  a 
certain  part  of  a  Hmb,  we  must  not  assume  that  the  area  in  question 
ends  abruptly.  This  is  in  accordance  with  Nature's  laws.  The  colors 
of  the  rainbow  are  not  sharply  defined,  but  beautifully  blended.  The 
light  of  day  does  not  suddenly  cease  and  the  darkness  of  night  begin, 
but  the  atmosphere  catches  the  departing  rays,  and,  refracting  them  to 
the  earth,  changes  day  into  night  through  the  mellow  light  of  the 
gloaming.  So  it  is  with  the  brain  :  each  motion  or  each  part  of  a 
limb  has  a  special  point  which  controls  it  in  a  pronounced  manner,  but 
shading  off  from  this  point  the  neighboring  cortex  controls  it  also,  the 
power  lessening  as  we  go  away  from  the  special  focus.  If,  for  instance, 
the  portion  of  the  brain  which  controls  the  motion  of  the  thumb  be 
removed,  paralysis  of  the  digit  will  not  follow,  for  the  thumb  is  repre- 
sented, although  in  a  less  degree,  in  the  neighboring  areas.  It  is 
interesting  to  note  that  the  coarser  movements,  such  as  motion  of  the 
head,  the  shoulders,  the  trunk,  and  the  thighs,  have  their  centers  in  the 
anterior  portions  of  the  motor  area,  and  as  we  proceed  backward  the 
movements  which  are  represented  are  of  a  more  and  more  delicate 
character.  Thus  the  delicate  movements  of  the  face,  the  lips,  the 
fingers,  and  the  toes  have  their  centers  in  the  posterior  part  of  the 
motor  area.  Proceeding  backward,  the  centers  of  sensation  probably 
occupy  the  region  next  in  order  (Fig.  197),  and  lastly,  the  most 
delicate  of  all,  the  seat  of  vision. 

2.  The  Area  of  Speech. — Speech  has  a  wide  representation  and 
occupies  four  areas  in  four  different  locations — vdz. : 

{a)  Motor  spcccJi,  or  the  movements  required  in  the  production  of 
speech,  is  represented  in  the  posterior  part  of  the  third  frontal  convo- 
lution, on  the  left  side  in  right-handed  persons  and  on  the  right  side  in 
those  who  are  left-handed.  Just  behind  the  coronal  suture  and  running 
parallel  to  it  is  the  precentral  or  vertical  sulcus  (/g,  Fig.  196).  It  is 
the  anterior  boundary  of  the  motor  area.  It  lies  in  front  of  the  fissure 
of  Rolando,  and  is  separated  from  it  by  the  width  of  the  anterior  cen- 
tral convolution.  Around  the  lower  end  of  this  sulcus  the  anterior 
central  convolution  makes  a  bend,  and  lies  in  the  hollow  formed  by  the 
limbs  of  the  fissure  of  Sylvius.  This  area  is  called  the  operculum,  and 
in  it  is  Broca's  center  for  speech.  The  symptoms  produced  by  disease 
in  this  area  are  loss  of  the  use  of  language  and  the  power  of  speech. 
The  loss  of  power  to  convey  our  thoughts  by  writing  is  called  agraphia. 
The  center  representing  this  power  is  not  definitely  settled,  some  cases 
going  to  show  that  it  is  in  Broca's  center,  others  that  it  is  near  the 
area  of  the  hand  and  wrist. 

{B)  The  Auditory  Speech-area. — In  the  first  and  second  temporal 
convolutions  is  the  area  which  receives  the  sounds  of  words  and  retains 
the  memories  of  these  sounds.  Disease  in  this  region  causes  the  per- 
son to  lose  the  memory  of  words,  to  be  unable  to  recollect  the  names 
of  the  most  familiar  objects,  and  to  fail  to  understand  language  when 
he  hears  it. 

{c)  The  Area  of  Visual  Speech. — A  person  may  be  able  to  see  the 
words  of  printed   language,  but   may  not   understand   them,  and  is 


460  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

thereby  unable  to  read.     Such  symptoms  would  indicate  disease  in  the 
inferior   parietal   rei^non. 

3.  The  Area  of  Vision. — 'rins  centre  is  situated  in  the  cuneus 
and  the  occipital  lobe  of  the  brain.  Disease  here  causes  blindness  in 
half  of  both  retinae,  and  to  this  condition  the  name  hemianopsia  has 
been  applied.  From  the  right  half  of  each  retina  impressions  are  con- 
veyed to  the  left  side  of  the  brain,  and  from  the  left  half  of  each 
retina  to  the  right  cerebral  hemisphere.  Disease  of  the  visual  area 
therefore  causes  blindness  of  the  right  or  left  half  of  each  retina  ac- 
cording as  the  left  or  right  side  of  the  brain  is  affected. 

4.  The  area  of  hearing  is  located  in  the  first  and  second  temporal 
convolutions.  Disease  of  this  area,  if  confined  to  one  side  of  the  brain, 
does  not  produce  deafness,  for  the  reason  that  each  ear  has  a  connection 
with  both  hemispheres.  If  both  sides  of  the  brain  are  diseased,  deaf- 
ness is  complete. 

5.  Smell  and  taste  are  represented  at  the  tip  of  the  temporal 
lobe  (Fig.  196),  but  the  clinical  value  of  changes  in  these  senses  is  not 
very  great.  In  the  first  place,  both  are  easily  blunted  or  modified  from 
trifling  causes,  and,  in  the  second  place,  each  is  represented  on  both 
sides  of  the  brain. 

The  surgeon,  in  order  to  deal  with  injuries  and  diseased  conditions 
of  the  brain,  must  be  able  to  locate  the  various  areas  on  the  outer  sur- 
face of  the  skull.  For  finding  the  fissures  certain  rules  have  been  laid 
down,  which  we  shall  now  consider : 

1 .  The  fissure  of  Bichat,  which  lies  between  the  cerebrum  and  cere- 
bellum, is  readily  located  by  drawing  a  line  from  the  external  auditory 
meatus  to  the  external  occipital  protuberance.  This  line,  continued 
around  the  occiput  to  the  opposite  meatus,  corresponds  to  the  lateral 
sinus. 

2.  The  fissure  of  Rolando  is  the  most  important  of  all  the  fissures 
from  a  surgical  standpoint,  for  on  each  side  of  it  lies  the  sensori-motor 
area.  The  upper  limit  of  the  fissure  is  thus  located :  Measure  the  dis- 
tance from  the  glabella  to  the  external  occipital  protuberance ;  at  a 
point  which  represents  55.7  per  cent,  of  this  distance  is  the  beginning 

of  the  fissure.  For  all  practical  purposes 
a  point  a  half-inch  behind  the  middle  of  this 
line  is  sufficiently  accurate.  The  fissure 
runs  downward  and  forward  at  an  angle  of 
67°  ;  the  next  point,  therefore,  is  to  find 
that  angle,  and  for  this  purpose  several  ex- 
pedients have  been  adopted.  The  simplest 
and  readiest  is  that  of  Mr.  Chiene  of  Edin- 
burgh. A  square  piece  of  paper  (Fig.  198) 
is  so  folded  as  to  bisect  one  of  its  an- 
gles, BAD.  The  result  is  an  angle  of 
45°,  BAG.  The  angle  D  A  C  is  again 
o     ^v      .       .u  J    r  c        bisected  by  folding  the  paper  on  the  line  A 

198. — Chiene  s  method  of  fix-       _^  ,-'  ,9  i         <-        in        ■~^^ 

position  of  Roiandic  fissure.       F,  and  the  result  IS  an  angle  of  22^^".      1  he 

angle  BAG  (45°),  plus  the  angle  G  A  E 
(22^°),  makes  an  angle  of  67-^°,  which  is  near  enough  for  all  practical 
purposes.     The  side  A  B  is  then  applied  to  the  middle  line  of  the  scalp. 


INJURIES  AND  DISEASES   OF  THE  HEAD. 


461 


SO  that  the  point  A  is  half  an  inch  posterior  to  the  middle  of  the  line 
between  the  glabella  and  the  external  occipital  protuberance. 

The  line  A  E  will  represent  the  position  of  the  fissure  of  Rolando. 


I  .-^1 .  .  .61 ,  I  .s| .  I  .■»!  .  ,  »| .  I  ?|  .  ^ .«! . ,  o| 


\^sM.,.\^...\y..V..A 


Fig.  199. — Horsley's  cyrtometer  (as  modified  by  Dr.  Morris  J.  Lewis). 


The  length  of  the  fissure  is  3f  inches.  The  upper  third  of  this  line 
will  indicate  the  position  of  the  leg  area,  the  middle  the  arm  area,  and 
the  lower  the  face. 

Another  method  of  finding  the  angle  of  the  fissure  of  Rolando  is 
that  recommended  by  Horsley.  He  has  devised  a  cyrtometer  consisting 
of  two  strips  of  metal  or  parchment-paper, 
as  represented  in  Fig.  199,  the  long  arm  of 
which  is  14  inches  in  length  ;  to  this  a  lat- 
eral arm  is  attached  at  an  angle  of  67 '^. 
The  long  arm  is  graduated  each  way  from 
a  zero  point  half  an  inch  in  front  of  the 
short  arm.  The  long  arm  is  applied  to  the 
middle  line  in  such  a  way  that  the  glabella 
and  the  external  occipital  protuberance  will 
each  mark  the  same  distance  from  the  zero 
point.  The  short  arm,  being  half  an  inch 
behind  this  point,  will  correspond  with  the 
fissure  of  Rolando,  and  the  figures  3I  on 
the  scale  will  represent  the  length  of  the 
fissure. 

3.  The  fissure  of  Sylvius  is  found  as  fol- 
lows :  First  draw  a  base  line  from  the  lower 
margin  of  the  orbit  to  the  auditory  meatus ; 
draw  a  line  parallel  to  this  from  the  external 
angular  process  running  backward  one  inch 
and  a  quarter  and  then  upward  one  quarter 
of  an  inch.  This  point  represents  the  be- 
ginning of  the  fissure  of  Sylvius.  From  it 
to  the  parietal  eminence  draw  another  line, 
and  it  will  represent  the  course  of  the  fis- 
sure, which  is  four  inches  in  length.  The 
anterior  limb  of  the  fissure  is  two  inches 
behind  the  external  angular  process.  An- 
other method  of  finding  the  fissure  of  Sylvius  is  as  follows  :  From  the 
external  angular  process  (Fig.  200),  E  A  P,  to  the  external  occipital 


Fig.  200. — Head,  skull,  and 
cerebral  fissures  (adapted  from 
Marshall  by  Hare)  :  B  corre- 
sponds to  Broca's  convolution ; 
EAP,  external  angular  process  ; 
FR,  fissure  of  Rolando ;  IF,  in- 
ferior frontal  sulcus  ;  IPF,  intra- 
parietal  sulcus ;  MMA,  middle 
meningeal  artery  ;  OPr,  occipital 
protuberance  ;  PE,  parietal  emi- 
nence ;  POF,  parieto-occipital 
fissure ;  SF,  Sylvian  fissure ;  A, 
its  ascending  limb ;  TS,  tip  of 
temporo-sphenoidal  lobe.  The 
pterion  (to  the  left  of  B)  is  the 
region  where  three  sutures  meet — 
viz.  those  bounding  the  great 
wing  of  the  sphenoid  where  it 
joins  the  frontal,  parietal,  and 
temporal    bones. 


462  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

protuberance  draw  a  line  passing  about  half  an  inch  above  the  auditory 
meatus.  At  a  point  upon  this  line  one  and  one-eighth  inches  from  the 
external  angular  process  draw  another  line  to  the  parietal  eminence, 
P  E ;  this  corresponds  with  the  main  branch  of  the  fissure  of  Sylvius. 
The  anterior  ascending  branch  follows  the  squamoso-sphenoidal  suture 
for  its  entire  length  and  ascends  about  half  an  inch  higher. 

II.    INJURIES   AND   DISEASES  OF  THE  SCALP. 

Contusions. — Bruises  of  the  scalp  are  frequently  met  with,  and 
claim  special  attention  owing  to  one  peculiarity — namely,  the  resem- 
blance of  their  symptoms  to  those  of  fracture  of  the  skull.  When  a 
blow  is  received  upon  the  head,  swelling  begins  almost  at  once,  and  is 
due  to  extravasated  blood  and  effused  serum.  The  swelling  is  soft  in 
the  center,  and  is  sharply  defined  at  the  circumference,  instead  of  blend- 
ing with  the  surrouncling  parts.  These  features  give  the  appearance 
of  a  depressed  fracture,  and  should  there  chance  to  be  a  small  ruptured 
vessel  in  the  center,  pulsation  of  the  brain  is  very  closely  simulated. 

The  diagnosis  between  this  and  depressed  fracture  is  made  by  press- 
ing firmly  with  the  finger  at  the  bottom  of  the  depressed  area.  If  it 
is  a  simple  contusion,  the  surface  can  be  still  further  indented  and  the 
smooth  bone  can  be  felt  beneath.  The  surrounding  swelling  "  pits  "  on 
pressure.  This  i.snot  the  case  in  fracture.  When  the  bone  is  depressed 
there  is  also  compression  of  the  brain,  as  a  rule,  while  this  is  absent  in 
contusion,  unless  there  is  at  the  same  time  rupture  of  a  vessel  within 
the  skull  which  is  forming  a  clot  of  blood  on  the  cerebral  surface. 
Compression  caused  in  the  last-mentioned  manner  does  not  come  on 
immediately  after  the  receipt  of  the  injury. 

The  treatment  of  contusions  consists  in  moderate  pressure  and  the 
application  of  lead-and-opium  lotion. 

For  the  relief  of  swelling  and  pain  massage  acts  most  satisfactorily. 
If  a  slight  abrasion  of  the  skin  is  made  by  the  blow,  suppuration  may 
follow  and  an  abscess  form  beneath  the  scalp,  which  must  be  promptly 
evacuated. 

The  most  important  part  of  the  treatment  consists  in  guarding 
against  complications  ;  for  symptoms  of  inflammation  of  the  brain  may 
set  in  or  inflammation  may  extend  over  the  whole  scalp,  or  a  traumatic 
aneur>'sm  may  form  beneath  the  scalp,  any  of  which  must  be  met  with 
its  appropriate  treatment. 

Cephalhematoma,  or  caput  succedaneum,  is  readily  recognized 
as  a  soft  tumor  seen  on  new-born  infants,  and  generally  at  the  parieto- 
occipital region.  It  is  the  effect  of  prolonged  pressure  during  labor. 
In  most  cases  no  treatment  is  required,  the  swelling  disappearing  at  the 
end  of  two  or  three  days.  Should  it  prove  unusually  obstinate,  as  I 
have  seen  in  two  cases,  the  fluid  may  be  aspirated  and  pressure  applied. 

Wounds  of  the  scalp  would  not  need  special  mention  were  it  not 
that  they  are  liable  to  be  followed  by  serious  consequences  which  do  not 
threaten  wounds  of  other  parts.  Patients  suffering  from  scalp-wounds 
are  usually  taken  to  the  nearest  drug-store,  where  an  artistic  dressing 
of  strips  of  sticking  plaster  is  arranged  in  a  stellate  or  a  tessellated 
pattern.     Of  all  dressings,  probably  sticking  plaster  is  the  worst ;  it  is 


INJURIES  AND  DISEASES   OF  THE  HEAD. 


463 


not  aseptic,  and  it  confines  the  pus  which  is  sure  to  form  in  a  wound  so 
treated.  From  the  scalp  the  pyogenic  germs  may  find  their  way  along 
the  vessels  which  perforate  the  skull,  and  thus  reach  the  brain  itself. 

In  dressing  a  wound  of  the  scalp  the  greatest  care  should  be  taken 
to  cleanse  the  injured  part.  The  hair  should  be  shaved  for  some  dis- 
tance around  the  incision ;  all  impurities  should  be  got  rid  of  by  wash- 
ing with  sterilized  water  and  then  with  sublimate  solution.  In  lacerated 
wounds  an  attempt  should  be  made  to  save  even  flaps  of  skin  which 
are  only  attached  by  narrow  pedicles,  for  the  blood-supply  of  the  scalp 
is  so  abundant  that  the  vitality  of  these  pieces  is  likely  to  be  maintained. 
The  edges  should  be  brought  together  and  held  by  stitches  of  catgut 
or  silkworm  gut,  and  an  antiseptic  dressing  applied.  For  small  wounds 
here  or  elsewhere  iodoformized  collodion  forms  a  simple  and  easily 
applied  dressing. 

Tumors  of  the  Scalp. — The  most  common  by  far  of  scalp-tumors 
are  sebaceous  timiors,  or  iveiis  (Fig.  201).     They  are  readily  recognized 


Fig.  201. — Sebaceous  cysts  of  scalp  (from  a  photograph  in  the  collection  of  Dr.  Lincoln). 

by  their  rounded,  even  shape  and  their  being  painless.  They  cause 
inconvenience  simply  by  their  awkward  position,  the  patients  complain- 
ing that  the  tumors  annoy  them  when  combing  their  hair  or  interfere 
with  the  headgear.  They  are  usually  single,  but  frequently  multiple, 
and  their  growth  is  slow. 

The  treatment  is  extirpation.  After  disinfecting  the  scalp  the  hair 
can  be  parted  over  the  tumor  and  an  incision  made  through  the  skin 
down  to  the  cyst,  which  can  generally  be  dissected  out  without  evac- 
uating the  contents.  Or  the  whole  tumor  maybe  transfixed  with  a 
scalpel  and  the  cyst-wall  grasped  with  forceps  and  pulled  out.  In  any 
case  the  cyst-wall  must  be  totally  removed.  The  skin  is  brought 
together  with  sutures  and  a  dressing  applied. 

Fatty  tumors  are  sometimes  seen  on  the  scalp,  and  they  may  be 
confounded  with  wens.  They  are,  however,  flatter  and  more  deeply 
seated.  An  error  in  diagnosis  is  of  no  consequence,  as  the  treatment 
of  both  is  extirpation. 


464  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

Horns  and  warts  arc  easily  diagnosed.  Horns  should  be  removed 
by  an  incision  including  their  base.  Warts,  if  showing  a  tendency  to 
rapid  growth,  are  probably  malignant,  and  should  be  extirpated. 

Pneumatocele,  or  a  tumor  containing  air,  has  been  found  on  the 
scalp  in  ioca.ses  reported  by  Treves.  The  tumor  is  recognized  by  its 
being  painless,  smooth,  elastic,  and  tympanitic.  It  is  produced  by 
erosion  of  the  osseous  tissue,  allowing  escape  of  air  from  the  mastoid 
cells  into  the  subcutaneous  tissue. 

The  treatment  is  pressure  after  evacuation  of  the  air  by  a  hypoder- 
mic needle. 

III.   INJURIES  OF  THE   SKULL. 

Contusions. — In  other  parts  of  the  body  a  contusion  of  bone  is 
liable  to  be  followed  by  osteo-myelitis,  and  such  is  the  case  in  bones  of 
the  skull ;  but  the  mischief  does  not  end  here,  for  a  chain  of  symptoms 
may  follow  such  an  injury,  showing  that  the  inflammatory  process  has 
spread  from  the  bone  to  deeper  structures.  The  blow  which  causes 
contusion  of  bone  may  produce  hemorrhage  between  the  pericranium 
and  the  skull.  The  effusion  of  blood  and  the  inflammation  which  fol- 
low strip  the  periosteum  from  the  bone  and  necrosis  is  the  result ;  or 
the  blow  may  crush  the  cancellous  tissue  or  rupture  the  veins  of  the 
diploe,  or  the  vessels  which  run  between  the  dura  mater  and  the  inner 
surface  of  the  skull  may  be  ruptured,  and  hemorrhage  occur  in  that 
situation.  The  effects  of  a  contusion  of  the  skull  may  be  summed  up 
as  follows : 

1.  Osteo-myelitis  with  separation  of  the  pericranium.  The  symp- 
toms here  are  local  pain  and  tenderness,  inflammation,  and  perhaps  the 
formation  of  an  abscess.  There  is  dull  headache,  but  the  constitutional 
symptoms  are  slight.  The  osteitis  may  be  acute  or  may  continue  for 
years.  A  ver>'  characteristic  symptom  of  osteo-myelitis  of  the  skull  is 
the  so-called  "puffy  tumor"  of  Pott.  It  is  a  flattened,  circumscribed 
swelling  over  a  spot  w^hich  is  very  tender  on  pressure. 

2.  The  inflammation  may  extend  to  the  dura  mater.  If  blood  has 
been  poured  out  at  the  time  of  the  injury,  so  as  to  separate  the  dura 
mater  from  the  bone,  the  condition  is  thereby  rendered  more  serious. 
The  symptoms  are  still  local.  Inflammator>'  products  or  a  collection 
of  pus  may  produce  pressure-symptoms,  but,  as  a  rule,  it  is  only  when 
the  third  step  is  reached  that  these  signs  appear. 

3.  The  inflammation  extends  to  the  arachnoid.  Up  to  this  point  the 
inflamed  area  is  localized,  but  now  it  extends  over  the  surface  of  the 
membrane.  From  this  membrane  the  extension  to  the  pia  mater  and 
the  brain  itself  is  unimpeded.  The  symptoms  change  accordingly. 
The  patient  complains  of  malaise,  headache,  stiffness  of  the  muscles  of 
the  neck,  giddiness,  chilliness,  nausea,  and  vomiting.  The  temperature 
rises,  and  the  senses  of  sight  and  hearing  become  abnormally  acute. 
The  location  of  the  disease  and  its  gradual  advance  can,  in  some  cases, 
be  followed  by  noting  the  effects  upon  the  motor  areas.  Thus  a  loss 
of  motion  of  the  arm,  followed  by  a  similar  loss  in  the  leg,  would  indi- 
cate a  spread  of  the  inflammation  upward  along  the  sensori-motor  area, 
and  would  also  be  an  indication  to  trephine  the  skull  over  the  part  of 
the  brain  suffering  pressure.     If  the  disease  advances,  stupor,  drowsi- 


INJURIES  AND  DISEASES   OF  THE  HEAD.  465 

ness,  paralysis,  and  coma  supervene,  and  the  patient  dies.  After  a  blow 
upon  the  head  we  should  watch  carefully  for  cerebral  symptoms,  not 
feeling  that  the  patient  is  safe  until  three  weeks  shall  have  passed  with- 
out appearance  of  this  complication.  The  second  week  is  probably  the 
most  critical  period. 

Treatment. — The  smallest  breach  of  skin  upon  the  head  should  be 
dressed  with  great  care,  lest  septic  germs  should  gain  an  entrance  to 
the  contused  bone  and  its  coverings.  The  treatment  must  aim  at  pre- 
venting osteo-myelitis,  meningitis,  and  inflammation  of  the  brain  itself. 
Perfect  quiet  should  be  maintained  and  the  simplest  diet  enjoined.  The 
bowels  should  be  kept  freely  open  by  calomel  or  other  purgatives.  Cold 
applications  to  the  head  are  required  when  there  is  the  slightest  indica- 
tion that  the  inflammation  is  taking  a  direction  inward.  Sedatives  are 
necessary  to  relieve  headache,  and  for  this  purpose  the  bromids  are  the 
best.  When  symptoms  of  pressure  appear  in  the  form  of  localized 
paralysis,  such  as  of  the  arm,  leg,  or  face,  the  part  of  the  motor  area 
of  the  brain  indicated  should  be  exposed  by  a  large  trephine  opening 
with  the  view  of  getting  rid  of  pus. 

Fractures  of  the  Skull. — As  far  as  the  bones  themselves  are 
concerned,  there  is  nothing  remarkable  about  fractures  of  the  skull. 
Union  takes  place  as  readily  here  as  in  other  parts  of  the  bony  frame- 
work, and,  as  a  rule,  the  repair  is  such  as  to  leave  little  if  any  thicken- 
ing or  deformity.  The  traumatism,  however,  which  is  severe  enough 
to  break  the  skull  is  almost  sure  to  injure  the  brain,  or  the  displaced 
fragments  may  be  driven  in  upon  the  brain  and  its  meninges,  leading  to 
the  most  serious  consequences. 

Fractures  of  the  skull  are  divided  into  those  of  the  vault  and  those 
of  the  base. 

Fractures  of  the  Vault. — If  a  force  applied  to  a  limited  area  of  the 
skull  is  sufficient  to  make  the  bone  yield,  the  effect  will  be  {a)  a  fissure 
or  crack  in  the  skull,  and  it  may  extend  for  a  considerable  distance 
from  the  point  to  which  the  force  has  been  applied.  It  is  not  uncom- 
mon to  find  a  fissure  which  has  run  across  sutures  from  one  bone  to 
another  or  has  even  extended  so  as  to  involve  the  base  itself.  (/;)  The 
bone  may  be  comminuted  at  the  point  of  contact,  (r)  The  fracture  may 
be  opposite  to  the  point  of  contact,  the  so-called  fracture  by  contrc- 
coup  or  counter-stroke,  {d^  To  the  above  I  shall  add  a  fourth  class,  in 
which  the  force  may  cause  fracture  at  a  part  of  the  skull  which  is  dis- 
tant from  the  point  of  contact,  but  not  opposite  to  it.  This  is  well  seen 
in  Fig.  202.  The  wounds  of  entrance  and  exit  of  a  bullet  are  seen  at 
opposite  sides  of  the  calvarium,  while  between  them  is  a  fissure 
extending  nearly  the  whole  length  of  the  vault  from  the  frontal  to 
the  occipital  bones. 

Symptoms. — In  examining  the  skull  for  fracture  pass  the  fingers 
gently  over  the  vault  to  ascertain  the  existence  of  any  depression  or 
sharp  edges  of  bone.  In  many  cases  the  fracture  is  compound,  and 
the  examination  is  made  at  the  bottom  of  the  scalp-wound.  The 
wound  itself  should  be  carefully  examined  for  splinters  of  bone  or 
portions  of  brain-tissue.  The  finger,  carefully  disinfected,  can  now 
explore  the  wound,  searching  for  depressions,  fragments,  or  fissures. 
Next  the  edges  of  the  wound  are  held  apart,  so  that  the  tissues  may 


466  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

be  seen.  The  fractured  edge  of  bone  has  a  dark-red  color.  A  fissure 
may  in  some  cases  be  detected  by  its  holding  in  its  grasp  one  or  more 
hairs.  A  very  old  and  infallible  sign  of  fracture  is  the  nature  of  the 
clot  which  is  found  in  the  wound :  if  there  is  no  fracture,  this  clot  can 
be  wiped  away;  in  the  case  of  fracture  no  amount  of  washing  or  wiping 
can  dispose  of  the  clot. 

Simple  fracture  must  be  determined  by  the  depression  which  is  felt 
through  the  scalp.  Care  must  be  taken  to  distinguish  this  depression 
from  the  effusion  of  blood  which  takes  place  after  a  bruise  of  the  scalp, 
the  diagnostic  importance  of  which  has  already  been  dwelt  upon. 
Another  symptom  which  can  sometimes  be  elicited  is  the  "  cracked- 
pot  "  sound  heard  on  auscultatory  percussion.  In  some  cases  it  is  so 
distinct  as  to  be  heard  without  the  aid  of  a  stethoscope,  and  even  by 


Fig.  202. — Fracture  of  the  vault  (from  a  photograph  in  the  collection  of  Dr.  C.  H.  Hunter). 

the  bystanders.  Rarely,  it  happens  that  the  dura  mater  is  wounded, 
and  cerebro-spinal  fluid  escapes  through  the  fractured  skull  and  forms 
a  translucent  tumor  beneath  the  skin.  This  tumor  is  recognized  by  its 
becoming  tense  with  such  movements  as  sneezing  or  coughing,  and  is 
positive  proof  of  fracture. 

The  outer  table  of  bone  may  alone  be  broken.  In  such  a  case  the 
depression  is  but  slight  and  the  cerebral  symptoms  are  not  marked. 
The  inner  table  may  also  be  broken  alone.  The  symptoms  are  not 
sufficient  for  a  positive  diagnosis,  and  the  fracture  can  only  be  suspected 
when,  after  a  force  applied  to  the  head,  evidence  of  cerebral  inflamma- 
tion and  pressure  supervene. 

Treatment. — The  question  of  treatment  must  be  influenced  by  the 
amount  of  injury  which  the  brain  has  suffered.  The  bone  is  of  minor 
importance. 


INJURIES  AND  DISEASES   OF  THE  HEAD.  467 

In  simple  fracture,  without  evidence  of  compression  of  the  brain,  or  if 
compression  is  passing  off,  perfect  quiet  and  good  nursing  constitute  all 
the  treatment  required.  The  patient  should  be  kept  in  a  darkened  room, 
the  diet  should  be  light,  the  bowels  should  be  freely  moved  by  a  dose 
of  calomel.  The  head  should  be  shaved,  ice-bags  applied,  and  the 
patient  kept  in  bed  for  at  least  three  weeks.  When  there  is  marked 
depression  it  is  evident  that  the  brain  has  been  injured,  and,  although 
there  may  be  no  immediate  evidence  of  compression  or  other  injury  to 
the  brain,  the  proper  course  is  to  trephine  with  the  view  of  preventing 
these  complications.  A  depression  of  the  skull  is  a  perpetual  source 
of  danger,  for  if  there  be  no  immediate  effects  there  may  be  developed 
at  even  a  remote  period  insanity  or  epilepsy. 

In  compound  fracture  of  the  vault  the  wound  requires  most  care- 
ful attention.  The  whole  scalp  should  be  shaved,  instead  of  a  small 
portion  around  the  wound,  as  is  too  generally  the  custom.  After 
washing  and  disinfecting  with  corrosive-sublimate  solution  (i  :  2000), 
and  having  arrested  all  hemorrhage  and  dried  the  parts,  the  surgeon 
next  directs  his  attention  to  the  condition  of  the  bone.  If  the  fracture 
is  a  simple  fissure  without  depression,  and  no  hairs  or  other  foreign 
substances  arr:  caught  in  the  fissure,  the  wound  may  be  closed  with 
catgut  sutures  and  a  copious  dressing  applied.  If  the  fissure  holds  in 
its  grasp  dirt,  hairs,  or  any  other  foreign  material,  the  edges  of  the 
fissure  should  be  chiselled  away,  removing  the  outer  table  of  bone  and 
leaving  a  V-shaped  groove.  Rubber  drainage-tubes  or  strands  of  cat- 
gut should  be  placed  in  position  and  the  wound  closed  and  dressed. 
When  there  is  depression  the  bone  must  be  elevated  to  its  proper  level 
and  loose  pieces  removed.  It  is  true  that  the  brain  can  endure  a  con- 
siderable degree  of  pressure,  and  that  many  patients  recover  in  whose 
brains  foreign  bodies  have  existed  for  years,  but  the  danger  is  always 
great.  In  skilful  hands  the  operation  of  trephining  is  not  of  itself  dan- 
gerous, but  it  should  be  resorted  to  as  a  preventive  measure,  and  not 
as  a  last  resort  when  the  patient  is  dying  of  brain-disease.  It  may  be 
sufficient  to  raise  the  bone  by  using  an  elevator,  care  being  taken  to 
bring  the  displaced  portion  up  to  its  former  level.  When  the  bones  are 
locked  together,  as  is  frequently  the  case,  it  is  necessary  to  remove  a 
portion  of  bone  with  the  trephine.  The  pericranium,  if  healthy  and 
uninjured,  should  be  carefully  preserved,  and  under  favorable  circum- 
stances the  button  of  bone  removed  by  the  trephine  may  be  replaced. 
After  dealing  with  the  fracture  the  wound  is  closed  and  dressed  in  the 
ordinary  manner. 

Punctured  wounds  of  the  brain  always  demand  the  use  of  the 
trephine. 

Fractures  of  the  Base  of  the  Skull. — Fractures  of  the  base  may 
occur  in  one  of  the  following  ways  :  {a)  A  fissure  of  the  vault  may  run 
downward  and  involve  the  base.  It  is  convenient  to  divide  fractures  of 
the  base  according  as  they  involve  the  anterior,  the  middle,  or  the 
posterior  fossa.  Fractures  extending  from  the  vault  are  apt  to  run  into 
the  middle  fossa  and  through  the  petrous  portion  of  the  temporal  bone. 
{p)  The  fracture  may  be  caused  by  indirect  violence,  as  when  a  person 
falls  from  a  height,  landing  in  a  sitting  posture,  and  communicating  the 
force  through  the  spinal  column  to  the  base  of  the  skull,     {c)  The 


468  SURGICAL   DIAGXOSIS  AND    TREATMENT. 

lower  jaw  may  be  driven  backward  with  such  force  as  to  fracture  the 
base,  {(i)  Punctiu'ed  fractures  can  occur  through  the  cavities  of  the 
orbit,  the  mouth,  and  the  nose. 

Syniptojiis. — There  is  one  leading  symptom  which  is  proof  of  frac- 
ture of  the  base,  and  that  is  escape  of  blood  and  cerebro-spinal  fluid 
from  the  ear.  This  sign,  however,  only  exists  when  the  fracture  is  in 
the  middle  fossa  and  involves  the  petrous  portion  of  the  temporal  bone. 
And  not  even  then  must  it  follow  that  blood  and  fluid  escape,  for  the 
membrana  tympani  must  first  be  ruptured.  Care  must  also  be  taken  to 
distinguish  between  this  kind  of  hemorrhage  and  bleeding  from  an 
ordinary  wound  in  the  ear.  If  it  be  a  simple  wound,  the  hemorrhage 
will  soon  cease ;  if  serum  escapes,  it  is  only  the  serous  oozing  which  is 
common  in  every  wound. 

When  there  is  fracture  the  bleeding  and  escape  of  cerebro-spinal 
fluid  arc  very  characteristic.  The  hemorrhage  continues  for  a  long 
time,  and  it  may  be  both  mixed  with,  and  followed  by,  the  watery  dis- 
charge. This  watery  fluid  escapes  more  profusely  when  the  patient 
increases  the  intra-cranial  tension  by  forced  expiration,  coughing, 
sneezing,  or  blowing  the  nose,  and  the  flow  is  also  influenced  by  the 
position  of  the  body.  The  fluid  should  be  collected  and  examined 
chemically.  It  contains  chlorids  in  large  amount,  a  trace  of  albumin, 
and  sometimes  sugar. 

There  are  other  positions  in  which  hemorrhage  can  be  taken  as  an 
indication  of  fracture  of  the  base — viz.  the  nose,  the  pharynx,  beneath 
the  deep  muscles  of  the  occiput,  and  the  tip  of  the  mastoid  process. 
In  any  of  these  positions  the  bleeding  is  characterized  by  its  long  con- 
tinuance, lasting  from  twenty-four  to  forty-eight  hours.  When  there  is 
fracture  of  the  orbital  plate  of  the  frontal  bone,  blood  will  appear  at  the 
end  of  one  or  two  days  as  an  ecchymotic  swelling  beneath  the  con- 
junctiva of  the  eyeball  and,  later,  in  the  lids.  An  ordinary  "  black 
eye  "  produces  ecchymosis  of  the  eyelid  first.  Hemorrhage  at  the  tip 
of  the  mastoid  process,  spreading  upward  and  backward  with  a  cres- 
centic  margin,  is  an  indication  of  fracture  of  the  posterior  fossa — a 
dangerous  fracture.  Escape  of  brain-matter  is  always  proof  of  fracture. 
It  is  usually  found  in  the  nose  or  pharynx. 

Paralysis  of  the  cranial  nerves  is  an  evidence  of  fracture  of  the  base. 
Deafness  and  facial  paralysis  frequently  go  together,  and  afford  evidence 
of  fracture  of  the  petrous  portion  of  the  temporal  bone.  Optic  neuritis 
is  evidence  of  fracture  of  the  posterior  fossa  (Battle). 

In  many  cases  the  diagnosis  of  fracture  of  the  base  can  only  be 
suspected.  If  a  fracture  of  the  vault  is  extensive  and  takes  a  direction 
downward,  we  may  infer  that  it  reaches  the  base.  A  piece  of  wood 
entering  the  orbit  must  fracture  the  skull  if  it  pierces  the  tissues  to  a 
greater  depth  than  the  orbital  cavity  extends,  and  an  umbrella  rib 
entering  the  floor  of  the  mouth  must  perforate  the  brain  unless  the 
wound  is  very  shallow. 

The  term  compound  fracture  has  a  wider  significance  here  than  in 
other  parts  of  the  body.  A  fracture  of  the  base  may  communicate 
w'ith  the  external  air  through  the  ear  or  the  nose  or  the  mastoid  cells, 
and  is  on  that  account  compound,  although  deep  within  the  cranium. 
It  is  important  to  keep  this  in  mind  in  considering  treatment. 


INJURIES  AND   DISEASES   OF   THE  HEAD.  469 

Treatment. — It  is  seldom  that  retentive  apparatus  is  required  to 
steady  the  fractured  bones.  When  the  traumatism  is  so  great  as  to 
render  this  necessary,  the  head  should  be  shaved,  covered  with  a  thin 
layer  of  absorbent  cotton,  and  enclosed  in  a  plaster-of-Paris  cast. 

In  the  majority  of  cases  treatment  will  consist  in  keeping  the  patient 
perfectly  quiet  and  preventing  sepsis  in  the  injured  part.  The  portals 
of  entrance  for  septic  germs  are  the  ear,  the  nose,  the  eye,  and  the 
mouth.  The  ear  must  be  thoroughly  cleansed  from  blood,  dirt,  and 
wax,  irrigated  with  warm  corrosive-sublimate  solution,  packed  with 
iodoform  gauze,  and  covered  with  sublimate  dressing.  The  mouth  is 
kept  as  nearly  disinfected  as  may  be  by  the  frequent  use  of  antiseptic 
washes,  such  as  boracic  acid  or  a  solution  of  Seiler'5  antiseptic  tablets. 
The  nose  is  thoroughly  cleansed  by  peroxid  of  hydrogen  and  douches 
of  boracic  acid,  and  packed  with  sublimate  gauze  or  borated  cotton. 
The  orbit  requires  particular  attention  when  the  fracture  has  occurred 
by  that  route.  Drainage  is  the  first  consideration,  and,  if  this  cannot 
be  otherwise  secured,  the  roof  of  the  orbit  should  be  sufficiently  cut 
away  by  gouge  or  chisel  to  giv^e  free  exit  to  pus  and  other  products ; 
a  drainage-tube  can  be  placed  in  the  wound,  and  after  thorough  disin- 
fection an  antiseptic  dressing  can  be  applied.  The  middle  fossa  is  best 
drained  by  a  trephine  opening  above  and  behind  the  auditory  meatus. 
The  anterior  fossa  is  reached  through  the  nose  by  breaking  through 
the  cribriform  plate  of  the  ethmoid  bone  and  inserting  a  drainage-tube. 

IV.    INJURIES  OF  THE   BRAIN   AND   ITS   MEMBRANES. 

Concussion. — In  the  writings  of  the  older  authors  the  term  con- 
cussion was  used  to  imply  a  suspension  or  sudden  arrest  of  the  func- 
tions of  the  brain,  the  result  of  a  force  transmitted  through  the 
cerebro-spinal  fluid  to  more  or  less  distant  portions  of  the  brain, 
mainly  the  fourth  ventricle.  Authorities  of  to-day  are  pretty  well 
agreed  that  the  condition  known  as  concussion  is  the  result  of  actual 
injury  to  the  brain,  a  laceration  of  its  substance,  the  result  of  force 
applied  directly  or  indirectly.  Concussion  and  laceration  may  be  used 
almost  as  synonymous  terms.  In  this  connection  the  experiments  of 
Felizet  are  interesting.  He  filled  a  skull  with  paraffin  and  let  it  fall 
from  a  height  which  was  not  sufficient  to  fracture  the  skull.  On  exam- 
ination it  was  found  that  the  bone  was  unbroken,  but  at  the  point  of 
contact  the  paraffin  was  flattened,  proving  that  when  the  force  was 
applied  the  bone  was  driv^en  in,  and  then  by  its  resiliency  bounded 
back  to  its  place.  No  doubt  the  same  resiliency  exists  in  the  living 
skull ;  the  bone  rebounds,  but  the  brain  is  bruised  or  lacerated  and  a 
small  amount  of  hemorrhage  takes  place.  In  post-mortem  examina- 
tion of  cases  of  concussion  it  is  common  to  find  extravasation  of  blood 
into  the  meshes  of  the  pia  mater  and  beneath  the  arachnoid.  Accord- 
ing to  Duret,  these  are  due  to  the  waves  communicated  to  the  sub- 
arachnoid fluid,  the  force  of  which  may  have  its  greatest  intensity 
opposite  the  point  at  which  the  blow  is  received. 

Symptoms. — In  mild  cases  the  injured  person  turns  pale,  becomes 
giddy,  loses  his  balance,  and  falls.  He  may  lie  unconscious  or  semi- 
conscious, and  after  a  time  get  up  of  his  own  accord  or  with  slight 


470  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

assistance.  His  mind  is  confused  and  he  suffers  from  nausea,  and  per- 
haps vomits.  In  severe  cases  the  symptoms  are  much  more  serious. 
The  person  falls  suddenly,  and  lies  perfectly  still,  totally  unconscious 
or  capable  of  being  only  partially  roused.  The  heart  is  weak  and  the 
pulse  fluttering.  The  pupils  generally  respond  to  light,  but  they  may 
be  unevenly  contracted.  Vomiting  is  the  first  indication  of  returning 
consciousness.  After  the  patient  has  regained  consciousness  he  suffers 
from  headache,  vertigo,  and  lassitude,  and  this  may  continue  for  several 
weeks.  In  the  worst  cases  the  injury  to  the  brain  is  so  great  that  the 
unconsciousness  deepens  into  coma,  or  the  symptoms  of  meningitis, 
cerebritis,  or  abscess  are  developed.  Remote  consequences  of  such 
injuries  are  epilepsy  and  insanity. 

Trcatiiicjit. — The  treatment  is  the  same  as  for  contusions  of  the 
skull — perfect  quiet  and  the  closest  watchfulness  for  brain-compli- 
cations. Among  the  laity  it  is  a  common  practice  to  give  alcoholic 
stimulants ;  this  is  to  be  condemned,  as  their  effects  upon  the  brain 
may  prove  serious.  Aromatic  spirit  of  ammonia  is  free  from  this 
objection,  and  should  headache  prove  troublesome  a  dose  of  bromid 
of  potassium  is  proper.  Every  case  of  concussion  should  be  looked 
upon  as  a  serious  injury,  and  no  amount  of  remonstrance  on  the  part 
of  the  patient  should  influence  you  in  relaxing  the  rigidity  of  your 
management. 

Compression  of  the  Brain. — An  organ  so  delicate  as  the  brain 
is  intolerant  of  pressure,  and  refuses  to  perform  its  functions  when  en- 
croached upon  by  foreign  bodies.  The  causes  of  compression  are — 
hemorrhage  above  or  below  the  dura  mater  or  in  the  center  of  the 
brain,  collections  of  pus,  hyperemia,  depressed  fractures,  and  tumors. 
The  time  at  which  evidences  of  compression  appear  varies  with  the 
nature  of  the  compression.  Rapid  extravasation  of  blood  produces 
immediate  compression  ;  inflammation  does  not  produce  it  until  the 
hyperemia  or  the  inflammatory  products  have  had  time  to  develop ; 
tumors  do  not  cause  compression  until  an  advanced  stage  of  their 
growth,  except  when  they  are  attended  with  hemorrhage  ;  in  meningitis 
or  osteo-myelitis  of  the  skull  this  symptom  does  not  appear  until  the 
second  week,  while  an  abscess  in  the  cerebral  substance  may  not 
reveal  its  presence  until  weeks  or  months  after  the  accident  which 
caused  it. 

Symptoms. — The  symptoms  of  compression  are  in  many  respects 
entirely  different  from  those  of  concussion,  and  yet  there  are  cases  in 
which  the  diagnosis  is  difficult,  as  one  condition  runs  into  the  other. 
There  are  degrees  of  compression  too,  for  in  one  case  the  whole  brain 
may  suffer,  in  another  the  pressure  may  be  local.  Sudden  compression 
may  begin  with  convulsions. 

Total  Compression. — The  patient  is  completely  unconscious  and  lies 
in  a  state  of  coma.  One  leading  symptom  is  very  pronounced,  and  can 
be  heard  the  moment  you  enter  the  patient's  room — stertorous  breath- 
ing. If  you  watch  the  cheeks,  you  will  see  that  they  expand,  and  the 
lips  are  passively  blown  outward  at  each  expiration.  This  is  because 
they  are  paralyzed.  In  concussion  we  saw  that  the  patient  could  be 
roused  to  semi-consciousness  :  not  so  in  compression,  for  voluntary 
and  reflex  movements  are  in  abeyance.     The  skin  is  cold,  and  usually 


INJURIES  A.\D   DISEASES   OF   THE   HEAD.  47 1 

it  is  covered  with  perspiration.  The  pulse  is  slow  and  strong.  The 
pupils  are  fixed,  generally  dilated,  and  do  not  respond  to  light.  The 
bladder  has  lost  its  power  to  contract,  and  becomes  over-distended ; 
the  feces  are  passed  involuntarily. 

When  the  cause  of  compression  acts  slowly  the  following  sequence 
of  symptoms  may  be  observed :  The  patient  becomes  restless  and  irri- 
table, and  complains  of  nausea  and  other  digestive  disturbances ;  there 
is  severe  headache  ;  the  pupils  are  contracted  ;  the  face  is  flushed  ;  the 
pulse  is  full  and  rapid,  and  the  beating  of  the  carotids  is  apparent  to 
the  eye.  Impairment  of  speech,  vomiting,  and  sometimes  convulsions 
precede  the  period  of  stupor,  which  lasts  as  long  as  compression  ex- 
ists. A  rise  in  temperature  is  a  symptom  of  great  importance,  and 
has  a  prognostic  as  well  as  a  diagnostic  value.  It  comes  on  early  and 
is  persistent.  A  subnormal  followed  by  a  high  temperature  demands 
a  bad  prognosis. 

Local  Couiprcssio)i. — The  patient  does  not  lose  consciousness,  and 
the  symptoms  will  depend  upon  the  part  of  the  brain  which  suffers 
compression.  The  anterior  lobes  show  the  least  response,  and  it  is  not 
uncommon  to  find  a  considerable  area  of  cerebral  tissue  destroyed 
without  having  shown  symptoms  during  life.  When  the  anterior  por- 
tion of  the  brain  is  compressed  no  paralysis  is  produced,  unless  the 
posterior  part  of  the  inferior  left  frontal  convolution  becomes  involved, 
in  which  case  there  is  motor  aphasia.  Pressure  in  the  motor  area  will 
be  recognized  by  paralysis  of  the  limbs  or  impairment  of  the  movements 
over  which  the  several  districts  preside,  as  follows  : 

Paralysis  of  the  lower  limb  indicates  the  upper  third  of  the  fissure 
of  Rolando  on  the  opposite  side  and  the  corresponding  parts  of  the 
ascending  frontal  and  ascending  parietal  convolutions  (Fig.  197). 

Paralysis  of  the  upper  extremity  indicates  pressure  upon  the  middle 
third  of  the  Rolandic  fissure  and  the  corresponding  parts  of  the  con- 
volutions. 

Motor  aphasia  indicates  pressure  upon  Broca's  area  in  front  of  the 
lower  third  of  the  fissure  of  Rolando.  Mind-blindness  may  be  caused 
by  pressure  of  the  angular  gyrus,  as  shown  by  a  case  of  Macewen's  in 
which  a  spiculum  of  bone  from  the  inner  table  was  driven  in  upon  the 
anterior  portion  of  the  convolution.  Word-blindness  (apraxia)  would 
point  to  the  temporo-sphenoidal  lobe  ;  hemianopsia,  to  the  cuneus  and 
its  neighborhood.  Pressure  upon  the  pons  Varolii  or  the  medulla 
oblongata  speedily  endangers  life  by  destroying  the  nerve-centers 
themselves  or  arresting  the  nerve-currents  as  they  pass  from  the  skull. 

In  the  diagnosis  of  compression  of  the  brain  the  following  must  be 
excluded :  alcoholic  intoxication,  opium-poisoning,  apoplexy,  and 
uremia.  A  drunken  person,  unless  carrying  a  very  heavy  "jag,"  is  not 
unconscious  ;  he  probably  has  the  appearance  of  habitual  indulgence 
and  the  smell  of  alcohol  taints  his  breath.  Doubt  may  arise,  however, 
from  various  sources  :  the  drunken  man  may  have  fallen  and  caused  an 
injury  to  his  head,  which  injury  may  divert  the  attention  of  the  examiner 
from  the  real  condition.  On  the  other  hand,  an  injured  person  is  almost 
sure  to  have  stimulants  poured  down  his  throat  by  those  who  come  to 
his  rescue.  The  pupils  of  a  drunken  man  are  usually  contracted,  but 
they  dilate  w^hen  he  is  aroused.     The  temperature  is  subnormal.     The 


472  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

effects  of  alcohol  pass  oft"  in  a  few  hours,  when  all  doubt  is  removed 
if  not  before. 

Opium-poisoning  is  attended  with  the  drowsiness  and  the  deep  sleep 
which  characterize  the  effects  of  opiates ;  the  pupil  is  contracted  to  a 
pin-point  and  remains  so,  and  there  are  no  evidences  of  an  injury  to 
the  head. 

Apopelxy  is  due  in  nearly  all  cases  to  hemorrhage  of  the  lenticulo- 
striate  artery,  which  Charcot  has  designated  "  the  artery  of  cerebral 
hemorrhage."  In  this  lesion  unconsciousness  comes  on  immediately  or 
after  a  very  short  interval ;  the  breathing  is  stertorous,  unconsciousness 
is  complete,  and  there  is  cither  hemiplegia  or  total  paralysis. 

Uremia  is  recognized  by  a  history  of  albuminuria,  edema  of  the  legs, 
and  the  absence  of  paralysis  and  stertorous  breathing. 

Treatment. — Compression  is  only  a  symptom,  and  its  treatment  must 
depend  upon  the  lesion  which  is  acting  as  the  cause. 

Intra-cranial  Hemorrhage. — Hemorrhage  within  the  skull,  as  a 
rule,  arises  from  one  of  three  arteries:  i.  The  lenticulo-striate  causes 
the  hemorrhage  of  apoplexy,  and  comes  under  the  consideration  of  the 
physician.  2.  The  middle  meningeal  produces  those  cases  in  which  the 
bleeding  is  outside  the  dura  mater.  3.  The  middle  cerebral  gives  rise 
to  hemorrhage  beneath  the  dura  mater — subdural  hemorrhage.  Other 
sources  of  intra-cranial  hemorrhage  are  the  sinuses,  the  small  vessels 
of  the  membranes,  and,  in  exceptional  cases,  the  internal  carotid  artery. 

The  cases  of  cerebral  hemorrhage  which  fall  under  the  care  of  the 
surgeon  are  nearly  all  of  traumatic  origin.  They  may  be  classed  under 
three  heads  :  {a)  extradural  hemorrhages,  or  those  which  occur  between 
the  dura  mater  and  the  skull ;  (Jj)  subdural,  or  those  which  take  place 
between  the  dura  and  the  brain ;  and  {c)  cerebral,  or  those  which  take 
place  into  the  tissue  of  the  brain  itself 

Extradural  Hemorrhage. — The  source  of  this  form  of  hemorrhage 
is  nearly  always  the  middle  meningeal  artery,  and  the  exciting  cause  is 
a  blow  or  a  depressed  fracture.  The  artery  is  a  branch  of  the  internal 
maxillary  and  enters  the  skull  throngh  the  foramen  spinosum ;  it  then 
divides  into  an  anterior  and  a  posterior  branch.  The  anterior  follows 
the  groove  in  the  great  wing  of  the  sphenoid,  and,  reaching  the  ante- 
rior inferior  angle  of  the  parietal  bone,  turns  upward  toward  the  middle 
line  of  the  head.  The  posterior  branch  passes  over  the  squamous 
portion  of  the  temporal  bone,  and  thence  to  the  posterior  margin  of 
the  parietal  bone.  One  or  other  of  these  branches  is  usually  the  seat 
of  extradural  hemorrhage — the  anterior  more  frequently  than  the 
posterior. 

Symptoms. — There  is  one  symptom  of  intra-cranial  hemorrhage 
which  is  worth  all  the  rest  combined.  //  is  a  period  of  consciousness 
after  the  first  shock  of  the  injury,  folloived  by  paralysis  or  unconscious- 
ness. Thus,  a  person  receives  a  blow  upon  the  head,  and,  falling  to  the 
ground,  remains  for  a  time  unconscious,  owing  to  concussion  of  the 
brain.  From  this  he  soon  recovers,  but  at  the  end  of  several  hours, 
or  it  may  be  one  or  two  days,  symptoms  of  compression  appear, 
manifested  by  paralysis  of  a  limb  or  gradually  increasing  stupor.  At 
the  time  he  received  the  blow  a  branch  of  the  artery  was  ruptured,  and 
the  blood  began  to  collect  and  form  a  clot  upon  the  surface  of  the 


INJURIES  AND   DISEASES   OF   THE   HEAD.  A.'Jl 

brain.  At  first  the  brain  could  tolerate  the  moderate  pressure  thus 
produced,  but  when  the  clot  became  larger  the  symptoms  of  compres- 
sion began  to  be  apparent.  When  paralysis  appears  it  is  upon  the  side 
of  the  body  opposite  to  the  brain-lesion,  and  may  involve  a  single  move- 
ment or  limb  or  take  the  form  of  hemiplegia.  In  some  cases  we  can 
trace  the  course  of  the  growing  clot  by  the  paralytic  symptoms.  Palsy 
of  the  muscles  of  the  face,  motor  aphasia,  paralysis  of  the  arm,  and 
later  of  the  leg,  would  indicate  that  the  clot  began  to  form  low  down 
near  the  base  and  gradually  ascended  to  the  middle  line.  The  patient 
becomes  drowsy,  and  the  drowsiness  may  deepen  into  coma.  The  pulse 
is  frequent,  and  in  contrast  to  it  the  respiration  is  slow  and  stertorous. 
If  the  clot  tends  to  increase  toward  the  base  of  the  brain  instead  of 
upward,  the  pupil  on  the  same  side  will  at  first  be  contracted,  and 
afterward  dilated  and  insensible  to  light.  It  occasionally  happens  that 
the  hemorrhage  takes  place  on  the  side  opposite  to  the  injury.  In  that 
case  the  injury  and  the  paralysis  will  be  upon  the  same  side. 

Subdural  hemorrhage  cannot  always  be  distinguished  from  the 
preceding  variety.  The  pressure  is  not  so  great  as  in  the  extradural 
form  ;  hence  the  pressure-symptoms  are  not  so  clearly  marked.  The 
blood  comes  from  the  middle  cerebral  artery,  from  the  vessels  of  the 
pia  mater  or  cortex,  or  from  the  veins  of  the  surface  of  the  brain. 
When  the  motor  area  is  the  seat  of  subdural  hemorrhage  the  para- 
lytic symptoms  are  the  same  as  those  observed  in  extradural  bleeding, 
but  less  marked  and  indefinite.  When  the  frontal  lobes  are  involved 
the  mental  condition  of  the  patient  becomes  changed,  as  shown  by 
irritability  of  temper,  loss  of  self-control,  and  sometimes  insanity. 

Subarachnoid  hemorrhage  is  not  recognized  by  any  symptoms 
which  distinguish  it  from  other  forms  of  intra-cranial  hemorrhage. 
The  blood  usually  comes  from  the  cortex  itself,  and,  if  it  does  not 
burst  through  the  arachnoid,  it  spreads  over  the  surface,  filling  the 
sulci  and  gravitating  toward  the  subarachnoid  space  at  the  base  of  the 
brain.  This  form  may  be  suspected  if  after  a  severe  contusion  the 
symptoms  are  local  at  first  and  rapidly  become  general,  attended  with 
convulsions  and  paralysis. 

Cerebral  hemorrhage,  or  hemorrhage  into  the  substance  of  the 
brain,  probably  occurs,  in  a  slight  degree,  in  most  cases  of  concussion, 
but  produces  no  definite  symptoms.  When  a  vessel  of  considerable 
size  is  ruptured,  the  blood  is  poured  out  into  the  ventricles  and  the 
case  is  one  of  apoplexy. 

Treatment  of  Intra-cranial  Hemorrhage. — When  signs  of  com- 
pression appear  within  a  few  hours  after  an  injury  hemorrhage  may 
be  almost  positively  diagnosticated.  The  treatment  must  be  deter- 
mined by  the  question  of  localization.  If  the  compression  is  general 
and  no  e.xact  point  can  be  fixed  upon  as  the  situation  of  a  clot,  we 
must  be  content  with  helping  the  flow  of  venous  blood  from  the  brain 
by  keeping  the  head  and  shoulders  slightly  raised  and  by  lessening  the 
amount  of  cerebro-spinal  fluid  through  the  influence  of  purgatives. 
Formerly,  venesection  was  resorted  to,  but  its  value  is  now  considered 
doubtful. 

When  the  position  of  the  clot  can  be  accurately  determined  by  local 
symptoms,  it  is  an  imperative  duty  to  trephine  the  skull,  remove  the 


474 


SURGICAL    JU A  GNOSIS  AND    TREATMENT. 


clot,  and  litj^atc,  if  possible,  the  bleeding  vessel.  When  the  middle 
menintjeal  artcr}'  is  the  bleeding  vessel,  which  is  the  case  in  the 
majority  of  injuries,  the  prognosis  is  not  necessarily  bad,  and  espe- 
cially if  it  is  the  anterior  branch  of  the  vessel  which  is  injured.  If 
there  is  a  fissure  of  the  skull  along  the  line  of  this  artery,  it  is  more 
than  likely  that  the  bleeding  point  is  just  beneath  the  fissure,  and  the 
trephine  should  be  applied  accordingly.  It  must  never  be  forgotten 
that  the  blow  may  be  on  one  side  of  the  head  and  the  hemorrhage  on 
the  opposite  side ;  the  paralytic  symptoms  in  that  case  would  be  on  the 
same  side  as  the  accident.  In  operating,  therefore,  the  point  for  tre- 
phining must  be  chosen  not  from  the  position  of  the  original  injury, 
but  by  the  localizing  symptoms.  Thanks  to  the  observations  of 
Kronlein,  there  is  one  point  at  which  we  are  almost  sure  to  find  the 
clot,  and  that  is  one  and  a  quarter  inches  behind  the  external  angular 
process  and  on  a  level  with  the  upper  margin  of  the  orbit  (P1g.  203). 


Fig.  203. — Site  of  trephine  opening  to  reach  clot  in  hemorrhage  from  middle  meningeal 
artery  (Kronlein) :  a,b,  horizontal  line  through  the  meatus;  c,  d,  on  a  line  with  the  eyebrows; 
e,f,  vertical  line  3  to  4  cm.  behind  the  ext.  ang.  process;  g,  h,  at  the  posterior  border  of  the 
mastoid  process.     A,  the  point  to  reach  the  anterior,  and  B,  the  posterior  branch. 


This  reaches  the  anterior  branch  of  the  middle  meningeal.  If  there  are 
dilatation  of  the  pupil  and  other  evidences  that  the  clot  is  increasing 
downward,  this  opening  must  be  made  half  an  inch  lower.  Should  we 
be  disappointed  by  this  exploration,  we  must  immediately  look  for  the 
clot  at  the  position  of  the  posterior  branch  of  the  artery.  This  is 
reached  by  trephining  farther  back — viz.  on  the  same  level  as  the 
former  opening  and  just  below  the  parietal  eminence. 

When  the  clot  is  reached  it  presents  the  appearance  of  a  dense, 
almost  black  coagulum  bulging  into  the  opening.  This  must  be  care- 
fully scooped  out,  and  if  the  trephine  opening  does  not  give  sufficient 
room,  the  bone  must  be  further  removed  by  Keen's  or  Hoffman's  cut- 
ting forceps.  Having  got  rid  of  the  clot,  the  next  and  most  difficult 
task  is  to  find  the  bleeding  point.  If  the  blood  keep  welling  up  as  fast 
as  it  can  be  sponged  away,  the  carotid  artery  should  be  compressed, 
and  sterilized  water  at  a  temperature  of  110°  should  be  applied  to  the 


INJURIES  AND  DISEASES   OF  THE  HEAD.  475 

wound.  When  the  bleeding  point  is  found,  a  catgut  ligature  should  be 
passed  around  the  vessel  by  means  of  a  full-curved  Hagedorn  needle, 
the  point  of  the  needle  being  made  to  enter  the  dura  mater  at  one  side 
of  the  artery,  and,  passing  under  the  vessel,  emerge  at  the  other  side. 
The  ligature  is  then  tied  so  gently  as  not  to  rupture  the  vessel.  Another 
difficulty  in  stopping  the  bleeding  point  is  that  the  part  of  the  brain 
occupied  by  the  clot  does  not  rise  to  the  opening  when  the  clot  is 
removed,  but  remains  depressed.  This  may  require  a  further  enlarge- 
ment of  the  trephine  opening.  Having  found  and  secured  the  bleeding 
vessel,  the  wound  is  well  cleansed  and  ample  drainage  provided  for. 

The  Operation  of  Trephining. — As  this  operation  is  a  preliminary 
to  nearly  all  the  operations  which  can  be  performed  on  the  brain  and 
involves  the  technique  of  all  cerebral  operations,  let  us  consider  it  in 
detail.  It  is  indicated  for  the  removal  of  a  depressed  bone  in  fracture 
of  the  skull,  for  intra-cranial  hemorrhage,  for  the  evacuation  of  cerebral 
abscess,  for  the  relief  of  epilepsy  or  insanity,  and  for  the  removal  of 
tumors. 

Preparation  of  the  Patient. — The  patient's  head  should  be  shaved  as 
the  very  first  proceeding,  since  his  examination  cannot  be  conducted 
satisfactorily  without  it.  It  is  remarkable  how  scars,  prominences,  and 
depressions  are  revealed  after  removal  of  the  hair.  The  nature  of  the 
lesion  having  been  arrived  at,  not  by  a  "  snap  "  diagnosis,  but  after 
careful  study  of  every  feature  of  the  case,  the  fissures  or  other  land- 
marks are  marked  by  an  anilin  pencil  or  by  a  stick  of  nitrate  of  silver. 
The  head  is  protected  by  a  suitable  cap  or  silk  handkerchief  The  day 
before  the  operation  the  scalp  should  be  again  shaven,  thoroughly  dis- 
infected, and  wrapped  in  sublimate  gauze.  When  the  patient  is  taken 
to  the  operating-room  a  final  washing  and  sterilizing  is  carried  out. 

AncstJicsia. — The  semi-recumbent  posture  is  believed  to  lessen  the 
amount  of  hemorrhage  during  the  operation.  Chloroform  is  un- 
doubtedly the  best  anesthetic. 

Raising  the  Flap. — Having  mapped  out  the  location  of  the  fissures 
upon  the  scalp,  it  is  very  important  that  corresponding  points  should 
be  marked  upon  the  bone.  The  sharp  point  of  a  trocar  or  the  center 
pin  of  a  spare  trephine  is  pushed  through  the  scalp,  and  by  rotary 
movement  or  a  sharp  stroke  of  a  hammer  is  made  to  mark  the  bone. 
In  any  case  the  point  to  which  the  trephine  is  to  be  applied  should  be 
marked,  and  if  the  operation  is  to  be  over  the  fissure  of  Rolando,  the 
upper  and  lower  end  of  the  fissure  should  also  be  marked. 

If  there  is  already  a  wound  in  the  scalp,  this  can  be  utilized  and 
enlarged  as  required.  In  the  uninjured  scalp  a  suitable  flap  must  be 
raised  and  the  bone  exposed.  Formerly  this  was  done  by  a  crucial 
incision,  but  it  had  several  disadvantages :  four  triangular  flaps  were 
constantly  in  the  way  and  had  to  be  held  aside ;  the  application  of 
sutures  to  close  the  wound  was  troublesome,  and  a  weak  point  was  left 
which  was  sure  to  come  over  the  center  of  the  opening,  where  the 
greatest  support  was  required. 

A  horseshoe  flap  is  the  shape  which  best  fills  all  requirements.  It 
should  have  its  base  below  when  practicable,  as  this  secures  better 
blood-supply.  The  incision  goes  through  the  pericranium,  and  the  flap 
is  raised  by  separating  the  pericranium  from  the  bone.     The  scalp  is 


476  SURGICAL   DIAGXOSIS  AND    TREATMENT. 

likely  to  bleed  freely,  but  this  is  readily  controlled  by  grasping  its 
edges  in  hemostatic  forceps.  The  operation  can  be  made  almost  blood- 
less by  apph'ing  a  stout  rubber  band  around  the  scalp,  just  above  the 
eyebrows  and  ears,  but  the  advantage  thus  gained  is  more  than  lost  by 
the  copious  hemorrhage  that  follows  removal  of  the  tourniquet.  For 
holding  the  flap  out  of  the  way  a  stout  silk  thread  can  be  passed 
through  its   margin  and  tied  to  form  a  loop. 

Trcphiiiino  the  Bone. — The  skull  is  now  exposed  to  view  and  is 
examined.  If  there  is  fracture  with  depression,  it  may  be  possible  to 
introduce  an  elevator  beneath  the  depressed  portion  and  restore  it  to  its 
proper  place.  If  the  bones  are  so  interlocked  as  to  make  this  impos- 
sible, the  trephine  must  be  used  to  get  rid  of  the  necessary  extent  of 
bone. 

When  the  object  of  the  operation  is  to  deal  with  an  intra-cranial 
lesion  a  good-sized  trephine  is  applied  over  the  spot  indicated  by  the 
mark  which  has  previously  been  made  on  the  bone.  The  point  of  the 
center  pin  hav'ing  become  well  engaged,  the  trephine  begins  to  cut 
through  the  bone  by  light  rapid  movements  from  right  to  left  and  from 
left  to  right.  Care  must  be  taken  to  keep  the  instrument  at  right 
angles  to  the  bone,  in  order  that  it  may  cut  through  evenly,  and  as  soon 
as  the  center  pin  has  ceased  to  be  necessary  it  is  retracted  and  fixed 
with  its  thumb-screw.  The  bone-dust  is  at  first  dry,  but  becomes  moist 
and  blood-stained  as  soon  as  the  outer  table  is  cut  through.  The  chan- 
nel made  by  the  saw  must  be  kept  clear  by  occasionally  using  a 
sterilized  toothpick  or  needle,  and  the  instrument  itself  freed  from 
debris  by  washing  it  in  carbolic-acid  solution.  When  the  diminishing 
resistance  gives  warning  that  the  bone  has  been  cut  through,  the  tre- 
phine is  laid  aside  and  the  button  of  bone  removed  by  gently  elevating 
it.  An  improv^ement  on  the  time-honored  trephine  has  been  devised 
by  Leonard  (Fig.  204).     It  has  a  fixed  handle  in  which  a  shaft  revolves, 


Fig.  204. — Leonard's  improved  aseptic  trephine. 

and  to  which  the  force  is  applied  through  a  double  raised  spiral  by 
means  of  a  sliding  handle.  By  each  upward  movement  of  the  sliding 
handle  the  shaft  and  trephine  are  caused  to  make  three  complete  revo- 
lutions. The  friction  is  less  and  the  cutting  more  easy  than  in  the 
ordinary  treatment. 

A  trephine  opening  to  be  of  any  utility  should  be  not  less  than  an 
inch  and  a  half  in  diameter.  Should  this  be  found  insufficient,  the 
opening  can  be  enlarged  by  rongeur  forceps  (Fig.  205).  Before  enlarg- 
ing, however,  the  dura  mater  is  to  be  separated  from  the  bone,  for 
which  purpose  Poirier's  (Fig.  206)  or  Horsley's  dural  separator  (Fig. 
207)  can  be  employed,  or  a  stout  probe  bent  to  a  proper  angle. 


INJURIES  AND  DISEASES   OF   THE  HEAD.  477 

Examination  of  the  Brain. — The  dura  mater  is  now  exposed,  and 
the  rule  is  to  open  it,  for  without  this  step  a  satisfactory  examination 
of  the  brain  cannot  be  made ;  but  it  must  be  borne  in  mind  that  unless 


Fig.  205. — Hopkins's  rongeur  forceps. 

the  most  thorough  asepsis  is  carried  out  the  risk  is  greatly  increased. 
The  cicatrix  which  follows  an  incision  of  the  dura  may  prove  trouble- 
some, and  should  be  taken  into  account.     The  membrane  is  divided 


Fig.  206. — Poirier's  dural  separator. 


Fig.  207. — Horsley's  dural  separator. 

with  curved  scissors  a  quarter  of  an  inch  from  the  edge  of  the  bone,  so 
as  to  form  a  flap,  which  at  the  end  of  the  operation  is  replaced  and 
stitched  to  the  quarter-inch  margin.  The  brain  now  lies  in  full  view, 
and  we  must  observe  the  following  points  : 

{a)  The  Degree  of  Tension. — Does  the  brain  bulge  into  the  trephine 
opening  ?  If  so,  there  is  an  increase  of  intra-cranial  pressure  due  to  a 
tumor,  an  abscess,  or  excess  of  fluid  in  the  ventricles. 

ib)  The  Color  of  the  Brain. — Lividity  or  a  yellowish  tinge  indicates 
a  probable  tumor  beneath  the  cortex.  An  old  laceration  has  a  dirty 
yellowish-brown  appearance.  A  dark  purple  substance,  seen  before 
opening  the  dura,  forced  up  into  the  trephine  opening  and  without  pul- 
sation, would  indicate  subdural  hemorrhage. 

{c)  Pulsation. — With  a  moderate  degree  of  compression  strong  pul- 
sation can  be  felt  and  the  resistance  is  increased ;  when  the  pressure  is 
due  to  a  large  underlying  tumor  or  abscess,  pulsation  is  absent. 

{d)  Faradization. — It  is  not  advisable  to  spend  much  time  in  testing 
the  motor-centers  by  faradization,  but  should  it  be  deemed  necessary 


478  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

to  follow  this  line  of  investigation,  an  ordinary  faradic  battery  with  a 
weak  current  is  sufficient.  A  very  convenient  electrode  is  that  devised 
by  Keen  (Fig.  2o8). 


Fig.  208. — Double  brain-electrode  (Keen) 


Operations  on  the  Brain. — If  the  aim  of  the  operation  is  the  arrest 
of  hemorrhage,  the  bleeding  vessel  can  be  secured  by  passing  a  full- 
curved  Hagedorn  needle  through  the  brain-tissue  and  beneath  the 
vessel,  and  tying  the  ligature  with  only  sufficient  tension  to  sto]3  the 
bleeding.  A  ligature  drawn  too  tightly  is  sure  to  tear  through  the 
delicate  tissues.  If  it  is  necessar>^  to  remove  a  diseased  portion  of  the 
brain-substance,  the  lines  of  incision  should  be  made  antero-poste- 
riorly,  as  in  that  direction  they  do  not  cut  across  motor  areas,  and  are 
therefore  less  likely  to  produce  paralysis.  If  a  tumor  is  to  be  removed, 
the  necessary  incision  through  the  cortex  should  be  made  at  right  angles 
to  the  surface  of  the  brain. 

Closing  the  Wotmd. — When  the  removed  portion  of  bone  is  in  a 
healthy  condition,  it  is  proper  to  replace  it.  With  this  object  in  view 
the  greatest  care  is  necessary  that  the  bone  should  be  properly  looked 
after.  One  assistant  should  have  this  matter  as  his  sole  charge.  As 
soon  as  the  bone  is  removed  he  should  place  it  in  a  bowl  containing  a 
I  :  2000  sublimate  solution,  and  keep  the  bowl  floating  in  water  at  a 
temperature  of  ioo°  to  105°  F.  All  bleeding  having  been  arrested 
and  the  wound  carefully  dried,  the  flap  of  dura  mater  is  replaced  and 
stitched  with  a  fine  catgut  continuous  suture.  The  bone,  if  healthy,  is 
cut  into  several  pieces  with  rongeur  forceps  and  laid  upon  the  dura. 
The  skin-flap  is  laid  in  position  and  stitched  with  catgut  or  silkworm 
gut.  If  the  case  is  one  of  abscess,  hemorrhage,  or  gunshot  wound,  a 
rubber  drainage-tube  should  be  placed  in  the  position  which  will  be 
most  dependent  when  the  patient  lies  in  bed.  The  outer  dressing  is  the 
same  as  for  any  other  wound. 

Wounds  of  the  Brain. — The  brain,  although  admirably  protected 
from  ordinary  violence,  may  yet  be  wounded  by  instruments  or  foreign 
bodies  penetrating  the  orbit,  roof  of  the  mouth,  or  the  cribriform  plate 
of  the  ethmoid  by  way  of  the  nose.  Instruments,  as  sabers,  bullets, 
knives,  or  bayonets,  applied  with  great  force,  may  even  penetrate  the 
skull  and  wound  the  brain.  The  wound  of  the  brain  in  all  these  in- 
stances is  a  complication  of  the  attending  compound  fracture  of  the 
skull.  The  symptoms  are  usually  overshadowed  by  the  fracture  or 
they  may  be  remarkably  slight  or  slow  in  making  their  appearance. 
Such  wounds  are  nearly  always  septic ;  consequently  there  is  evidence 
sooner  or  later  of  inflammation ;  the  patient  complains  of  headache, 
and  this  is  followed  by  the  group  of  symptoms  which  attends  cerebritis 
and  ends  in  death.  The  cortex  is,  as  a  rule,  the  part  that  suffers,  except 
when  the  wound  is  receiv^ed  by  the  mouth,  and  then  it  is  the  base  of  the 
brain.  In  many  cases  the  penetrating  body,  as  a  knife-blade  or  a  piece 
of  wood,  is  broken  off  and  left  within  the  cranium.     Such  a  case  came 


INJURIES  AND  DISEASES   OF  THE  HEAD. 


479 


under  my  observation  in  which  a  splinter  of  wood  about  half  an  inch 
square  and  six  inches  in  length  was  driven  into  the  orbit ;  the  wood  was 
immediately  withdrawn,  but  a  portion  three  inches  in  length  remained 
in  the  brain,  and  was  not  discovered  till  three  weeks  afterward,  when 
evidences  of  an  abscess  led  the  surgeon  to  operate.  Sometimes  the 
localizing  symptoms,  as  paralysis  of  the  face,  the  arm,  or  the  leg,  hemi- 
anopsia, aphasia,  etc.,  may  lead  to  a  diagnosis  of  the  position  of  the 
foreign  body. 

Treatment. — The  wound  is  to  be  thoroughly  cleansed  (the  head 
having  been  shaved),  all  pieces  of  bone  and  foreign  bodies  removed, 
and  every  effort  made  to  secure  asepsis ;  the  dura  mater,  if  practicable, 
should  be  united  by  sutures,  a  drainage-tube  placed  at  the  most  depend- 
ent part  of  the  wound,  the  scalp  closed  by  sutures,  and  a  full  antiseptic 
dressing  applied.  Suppuration  may  follow  in  spite  of  all  these  pre- 
cautions ;  abscesses  should  be  watched  for  and  promptly  drained. 

V.   INJURIES  OF  CRANIAL  NERVES. 

The  symptoms  that  indicate  injury  of  the  cranial  nerves  are  due 
either  to  a  lesion  of  the  part  of  the  brain  which  gives  origin  to  the 
nerves  or  to  injury  along  the  course  of  the  nerv^es  themselves. 

The  Olfactory  Nerve. — The  olfactory  nerve  begins  at  the  tuber 
olfactorium  in  front  of  the  anterior  perforating  space  (Fig.  209).     From 


Fig.  209. — Anterior  and  middle  portions  of  the  base  of  the  brain  (after  Hirt)  :  F,  frontal 
lobe;  7",  temporal  .lobe  ;  b.ol.,  olfactory  bulb  ;  /r.  (?/.,  olfactory  tract;  t.ol.,  tuber  (trigonum) 
olfactorium;  s.m.,  middle;  j. /.,  lateral  root;  /.,  infundibulum  (cut  off);  cm.,  corpora  albi- 
cantia  ;  /./.  a.,  anterior  perforated  space  ;  s.p. p.,  posterior  perforated  space. 


this  point  the  nerve  runs  forward  and  slightly  toward  the  middle  line, 
ending  in  the  olfactory  bulb  {b.  ol).  The  bulb  lies  upon  the  cribriform 
plate  of  the  ethmoid  bone,  and  through  the  minute  openings  of  this 
bone  two  sets  of  "fibers  pass  to  be  distributed  over  the  mucous  mem- 
brane of  the  nose.  The  deep  origin  of  the  nerve  is  not  positively 
known,  but  authorities  are  generally  agreed  that  there  are  three  roots. 
The  brain-center  of  the  sense  of  smell  is  also  a  disputed  point.     It  has 


480  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

been  placed  in  the  <jyru.s  hippocampi,  the  gyrus  uncinatus,  and  the 
cornu  ammonis.  Loss  of  smell  (anosmia)  is  not  a  symptom  upon 
which  much  reliance  can  be  placed.  The  sense  of  smell  may  be 
impaired  or  even  temporarily  lost  by  plugging  of  the  nostrils  with 
blood-clots,  by  acute  or  chronic  catarrh,  by  unnatural  dryness  of  the 
membrane,  or  b)'  constant  irritation.  Certain  occupations  produce 
anosmia;  soap-boilers,  workers  in  glue-factories,  butchers,  and  tanners 
suffer  in  this  way.  When  anosmia  follows  a  traumatism,  we  may  con- 
sider it  as  evidence  of  fracture  of  the  anterior  fossa  of  the  base  of  the 
skull,  or  possibly  a  momentary  separation  of  the  bulbs,  tearing  the 
nerves  across  at  their  origin  (Moullin).  Complete  loss  of  smell,  ac- 
cording to  Carbonicri,  strongly  suggests  diseases  of  the  olfactory  tract 
or  bulb. 

The  Optic  Nerve. — The  fibers  which  enter  into  the  formation  of 
the  optic  nerves  are  derived  from  the  optic  thalami,  the  outer  and  inner 
geniculate  bodies,  the  anterior  corpus  quadrigeminum,  and  the  cere- 
bellum. In  the  first  part  of  their  course  the  combined  fibers,  under 
the  name  of  the  optic  tracts,  converge  and  form  the  chiasm,  and  then, 
diverging  and  passing  forward  as  the  optic  nerves,  enter  the  orbit 
through  the  optic  foramina.  In  this  cavity  they  pass  through  the 
orbital  fat,  the  sclerotic  and  choroid,  and  spread  over  the  fibrous 
layer  of  the  retina. 

The  cortical  center  of  vision  has  not  yet  been  accurately  deter- 
mined. It  is  generally  admitted  that  it  is  in  the  mesial  surface  of  the 
occipital  lobe,  and  probably  in  the  angular  gyrus. 

Complete  blindness  would  indicate  that  the  nerve  was  torn  across 
at  the  foramen  or  that  it  had  been  crushed  by  a  fragment  of  bone  and 
afterward  became  atrophied.  Lateral  hemianopsia,  or  loss  of  sight  in  the 
corresponding  half  of  the  field  of  vision  in  both  eyes,  points  to  a  lesion 
of  the  tract  or  of  the  chiasm.  It  is  also  associated  with  disease  in  the 
occipital  lobe,  one  of  the  centers  of  the  optic  nerve.  It  is  possible  in 
some  cases  to  diagnosticate  the  location  of  the  injury  or  disease  from 
the  manner  in  which  the  symptom  appears.  If  it  occurs  suddenly  and 
is  the  only  symptom,  the  disease  is  in  the  cortex ;  if  other  symptoms 
accompany  it,  such  as  aphasia  or  hemiplegia,  the  lesion  is  not  in  the 
cortex. 

A  ready  method,  and  sufficiently  accurate,  of  examining  a  case  of 
hemianopsia  is  the  following  :  Place  the  patient  at  a  distance  of  two  feet 
from  the  examiner.  To  examine  the  right  eye  the  patient  covers  the 
left  eye  with  his  hand  and  the  examiner  covers  his  own  right  eye.  The 
patient  then  fixes  his  right  eye  on  the  left  eye  of  the  examiner.  The 
examiner  then  holds  up  his  finger  between  the  patient  and  himself,  and 
moves  it  in  different  directions  as  far  as  the  border  of  his  own  field  of 
vision,  the  patient  at  the  same  time  being  asked  how"^  far  out  he  is  able 
to  see  the  finger.  The  examiner  is  thus  enabled  to  notice  every  motion 
of  the  patient's  eye  toward  the  object,  and,  judging  from  his  answers, 
can  compare  the  patient's  field  of  vision  with  his  own  (Hirt). 

Loss  of  sight  in  the  inner  or  outer  side  of  both  retinae  indicate  that 
the  chiasm  is  the  seat  of  injury.  Choked  disk  or  papillitis  is  frequently, 
but  not  constantly,  found  in  connection  with  intra-cranial  tumors,  but 
the  theories  as  to  its  causation  are  up  to  the  present  time  conflicting. 


INJURIES  AND  DISEASES   OF  THE  HEAD.  48 1 

The  existence  of  this  symptom  affords  no  evidence  of  the  position  of 
the  tumor  or  of  its  pathological  character. 

The  third  nerve  leaves  the  brain  at  the  inner  margin  of  the  crus 
and  immediately  in  front  of  the  anterior  border  of  the  pons.  It  runs 
forward  and  outward,  and  after  entering  the  cavernous  sinus  divides 
into  two  branches.  Both  of  these  pass  through  the  sphenoidal  fissure 
into  the  orbit.  The  superioi  branch  supplies  the  levator  palpebrae 
superioris  and  the  superior  rectus.  Paralysis  of  this  branch  will 
therefore  produce  ptosis.  The  other  portion  of  the  nerve  divides  into 
three  branches — one  to  the  inferior  oblique,  one  to  the  inferior  rectus, 
and  one  to  the  internal  rectus. 

The  symptoms,  therefore,  which  point  to  paralysis  of  the  third 
nerve  are  ptosis,  external  strabismus,  dilatation  of  the  pupil,  and  loss 
of  power  of  aeconinioelation. 

The  fourth  nerve  (trochlear  or  pathetic)  leaves  the  brain  just 
behind  the  corpora  quadrigemina  at  the  upper  surface  of  the  valve 
of  Vieussens.  Passing  outward  and  downward,  it  winds  around  the 
outer  side  of  the  crus  and  appears  at  the  base  of  the  brain.  It  now 
turns  forward  to  the  cavernous  sinus,  and,  running  close  to  the  third 
nerve,  passes  through  the  sphenoidal  fissure  and  enters  the  superior 
oblique  muscle.  .  Paralysis  of  the  nerve  affects  only  the  superior 
oblique  muscle,  causing  diplopia.  A  very  early  symptom  is  giddi- 
ness when  going  down  stairs. 

The  sixth  nerve,  or  abducens,  leaves  the  brain  just  behind  the 
pons,  between  it  and  the  anterior  pyramid.  Running  forward,  it  enters 
the  cavernous  sinus,  accompanies  the  internal  carotid  artery,  and,  pass- 
ing through  the  sphenoid  fissure  to  the  orbit,  is  distributed  to  the 
external  rectus.  This  nerve  is  frequently  injured  in  traumatisms  of  the 
head,  and  such  injury  is  manifested  by  convergent  squint. 

The  fifth  nerve,  or  trifacial,  is  seldom  injured  alone.  It  frequently 
suffers  in  gunshot  wounds  through  the  mouth,  as  in  suicides.  When 
the  injury  is  at  the  origin  of  the  nerve,  there  is  complete  anesthesia  of 
the  corresponding  side  of  the  face.  Severe  neuralgic  symptoms  may 
be  taken  as  an  indication  that  the  sensory  portion  of  the  nerve  is 
affected.  A  more  severe  lesion  would  result  in  anesthesia,  with  a  cold 
and  purple  condition  of  that  side  of  the  face.  The  cutting  off  of  the 
nerve-supply  to  the  conjunctiva  causes  congestion  and  engorgement  of 
that  membrane,  the  tears  cease  to  flow,  and  the  saliva  ceases  to  be 
secreted.  The  consequent  dryness  of  the  nasal  cavity  causes  anosmia, 
and  of  the  mouth  loss  of  taste.  If  improvement  or  recovery  takes 
place,  it  is  fair  to  assume  that  the  paralysis  was  due  to  hemorrhage  or 
inflammatory  deposit. 

The  Seventh  Nerve. — The  first  division  of  this  nerve — the  portia 
dura,  or  facial  nerve — is  especially  liable  to  injury,  as  it  traverses  the 
long  bony  canal  in  the  petrous  portion  of  the  temporal  bone.  Frac- 
tures of  the  middle  fossa,  involving  this  portion  of  bone,  are  recognized 
in  a  great  degree  by  paralysis  of  the  facial  nerve.  When  the  paralysis 
does  not  come  on  immediately,  it  is  due  to  hemorrhage  or  inflammation  ; 
when  the  symptoms  are  immediate,  the  nerve  is  injured  by  compression 
of  a  fragment  of  bone  (Fig.  210). 

The  nerve  may  be  injured  as  follows : 

31 


482 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


Situation  of    Injury. 
At   origin   of  ue)~ve  .    . 


In  the  meatus 


Symptoms. 
Paralysis  of  same   side  of  face,   and   hemiplegia  of 
opposite  side  of  the  body.     The  sixth  is  generally 
paralyzed  also. 
Facial  paralysis  of  same  side.     The  auditory  is  in- 
jured, as  well  as  causing  deafness  of  same  side. 

In  the  aqueduct -j  Paralysis  is  confined  to  muscles  of  expression. 

I'he  petrosal  nerve   .    .    .    \  Paralysis  of  the  soft  palate. 
77ie  chorda  tyvipani  .    .    .    \  Loss  of  sense  of  taste. 

The  eighth  and  ninth  cranial  nerves  are  rarely  injured,  except 
in  traumatisms  of  extreme  gravity.     The  glosso-pharyngeal,  pneumo- 

gastric,  and  spinal  accessory,  all 
emerging  from  the  jugular  foramen, 
are  all  injured  alike  if  injured  at  all. 
In  a  case  recorded  by  Hilton  there 
was  great  difficulty  of  deglutition, 
the  tongue  was  thrust  to  the  oppo- 
site side,  articulation  was  slow,  and 
enunciation  imperfect.  Pain  was 
felt  in  the  neck  and  down  to  the 
clavicle  on  the  affected  side. 

VI.   GUNSHOT  WOUNDS  OF  THE 
HEAD. 

In  the  examination  of  gunshot 
injuries  of  the  head  the  following 
points  must  receive  attention:  i. 
The  wound  of  entrance ;  2.  The 
wound  of  exit ;  3.  The  position  of 
the  bullet ;  4.  The  extent  of  brain- 
injury. 

The  injury  produced  by  a  bullet 
is  often  more  serious  than  at  first 
sight  appears.  The  examiner  should 
therefore  be  on  his  guard  against 
saying  that  the  bullet  glanced  from 
the  skull,  causing  only  a  wound  of 
the  scalp.  In  such  cases  it  is  often 
found  that  the  outer  table  of  the 
skull  is  fissured  or  the  inner  table 


Fig.  210. — Schematic  representation  of  the 
trunk  of  the  facial  from  the  base  of  the  skull 
to  the  pes  anserinus  ;  different  localizations 
of  the  lesion  in  paralysis  (Striimpell) :  N.  f, 
facial  nerve  ;  TV.  /.  s,  great  superficial  petro- 
sal ;  N.  c.  c.  p.  t,  nerve  communicating  with 
the  tympanic  plexus  ;  N.  st,  stapedius  ;  C/i.  t, 
chorda  tympani ;  G.  /,  fibers  of  the  taste  ; 
S.  p.  s,  nerve  governing  the  secretion  of 
saliva ;  jV.  a,  acoustic  nerve  ;  C.  g,  geniculate 
ganglion ;  F.  st,  stylo-mastoid  foramen ; 
N.  a.  p,  posterior  auricular  nerve. 


is  fractured  or  depressed,  or  that 
there  is  injury  to  the  bone  sufficient  to  produce  osteitis  and  necrosis. 

Wounds  of  the  skull  are  spoken  of  as  non-penetrating,  penetrating, 
and  perforating.  If  the  bullet  enters  the  brain  and  remains  there,  it  is 
called  a  penetrating  wound  ;  if  it  passes  completely  through  the  skull, 
it  is  called  perforating.  The  wound  of  entrance  is  small ;  the  opening 
in  the  outer  table  is  often  the  same  size  as  the  bullet  or  it  may  be  a 
slit-like  hole.  The  inner  table  is  driven  in,  and  may  be  extensively 
fractured.  At  the  wound  of  exit  the  opening  in  the  inner  table  is 
small,  while  the  outer  table  may  display  an  opening  of  considerable 
extent. 

In  penetrating  wounds  the  question  of  the  position  of  the   bullet 


INJURIES  AND   DISEASES   OF   THE  HEAD.  483 

must  claim  attention.  Formerly  it  was  the  custom  to  let  the  bullet 
alone,  except  when  it  was  near  the  surface  and  easily  found.  It  is  true 
that  many  cases  recovered,  and  the  patients  carried  their  bullets,  with 
no  great  inconvenience,  through  a  natural  lifetime.  But  the  risk  was 
nev^ertheless  great ;  remote  effects  were  ever  liable  to  occur,  and  sudden 
death  from  the  presence  of  a  bullet  has  been  known  to  happen  as  late 
as  thirteen  years  after  the  injury.  Many  of  the  cases  die  of  cerebral 
abscess  ;  in  others  there  are  inflammation  and  softening  of  the  brain. 
Some  die  of  apoplexy,  and  others  drop  off  suddenly  after  years  of 
apparent  health.  The  experiments  of  Flourens  throw  light  upon  the 
latter  class.  He  introduced  bullets  into  the  upper  part  of  the  hemi- 
spheres of  the  brains  of  dogs  and  rabbits.  The  balls  by  their  own 
weight  gradually  sank  deeper  and  deeper  into  the  brain-substance,  and 
finally  reached  the  base  of  the  skull,  the  tracks  of  the  bullets  healing 
after  them.  The  same  thing  probably  occurs  when  bullets  are  lodged 
in  the  human  brain. 

Since  the  advent  of  antiseptic  surgery  the  bullet  can  be  sought  and 
removed  with  less  risk  than  formerly,  and,  as  a  rule,  the  brain  suffers 
less  from  exploration  than  from  the  continued  presence  of  a  foreign 
body. 

Finding"  the  Bullet. — Fluhrer  has  simplified  the  search  for  foreign 
bodies  in  the  brain  by  his  invention  of  the  aluminum  probe  which  bears 
his  name.  It  is  an  olive-pointed  probe  twelve  inches  in  length,  and 
composed  of  aluminum,  which  gives  it  the  quality  of  lightness.  The 
patient's  head  is  so  placed  that  the  wound  of  entrance  occupies  the 
highest  point,  and  the  supposed  track  of  the  bullet  is  in  a  perpendicular 
position.  The  probe  is  then  gently  inserted,  and  allowed  to  follow  the 
bullet  track  by  simple  gravdtation.  If  it  touches  the  ball,  the  pro- 
truding portion  of  the  probe  is  measured  and  an  estimate  formed  of 
the  distance  at  which  the  missile  lies  from  the  wound  of  entrance.  If 
near  this  wound,  it  may  be  extracted  by  enlarging  the  opening.  Some- 
times, however,  it  is  imbedded  so  deeply  that  it  is  nearer  the  opposite 
side  of  the  skull,  and  can  best  be  reached  by  a  counter-opening. 
Having  measured  the  distance  of  the  ball  from  the  wound  of  entrance, 
the  probe  is  pushed  on  till  it  reaches  the  counter-opening,  and  thus  the 
distance  from  the  latter  to  the  bullet  can  be  estimated.  Two  strands 
of  sterilized  silk  are  attached  to  the  end  of  the  probe  and  carried 
through  the  wound  as  the  probe  is  withdrawn.  One  of  the  threads  is 
made  use  of  to  draw  a  gum-elastic  catheter  through  the  wound  to  serve 
as  a  guide.  The  catheter  should  be  about  No.  9  French ;  it  should  be 
thoroughly  aseptic  and  made  firm  by  a  stylet.  Now  pass  a  loop  of 
silk  around  the  catheter  and  one  of  the  arms  of  a  pair  of  forceps,  and, 
thus  guided,  pass  the  forceps  along  the  catheter  in  search  of  the  bullet. 
The  greatest  gentleness  should  be  employed,  and,  failing  in  one  attempt, 
the  forceps  should  be  withdrawn  and  entered  at  another  point,  rather 
than  by  sweeping  it  around  the  catheter.  When  the  bullet  is  withdrawn 
a  rubber  drainage-tube  is  attached  to  the  second  thread  and  drawn 
through  the  wound. 

The  "  telephone  probe  "  of  Dr.  Girdner  is  very  ingenious,  and  has 
proved  a  valuable  aid  in  some  cases.  An  ordinary  telephone  receiver 
is  attached  to  the  probe ;  the  other  cord  of  the  receiver  is  connected 


484 


SURGICAL    DIAGNOSIS  AND    TREATMENT. 


with  a  metal  handle,  which  is  moistened  and  placed  in  the  patient's 
hand  or  a<^ainst  his  naked  skin.  The  examiner  then  places  the 
receiver  to  his  ear,  and  allows  the  probe  to  gravitate  along  the  bullet 
track  as  before.  Should  it  come  in  contact  with  the  bullet,  the  receiver 
intensifies  the  sound,  so  that  it  is  heard  with  great  distinctness. 

Lilicnthal  has  devised  a  bullet-probe  and  forceps  (Fig.  211)  which 
he  thus  describes  :  "  The  instrument  is  founded  upon  the  familiar  fact 
that  when  two  dissimilar  metals — as,  for  example,  a  silver  and  a  copper 
coin — are  held  simultaneously  in  the  mouth,  the  one  upon  the  tongue 
and  the  other  beneath  it,  a  distinct  and  unmistakable  electrical  sensa- 
tion, together  with  a  strong  metallic  taste,  is  perceived  as  soon  as  the 
metals  are  brought  in   contact,  but  not  before.      The  sensation  is  a 


Fig.  211. — Lilienthal's  bullet-probe  and  bullet-forceps. 

continuous  one  as  long  as  the  metals  touch  each  other.  Sensitive 
individuals  may  even  see  a  slight  flash  of  light. 

"  My  apparatus  consists  of  a  mouth-piece  made  of  two  metal  plates 
which  fit  at  the  sides  of  the  tongue,  one  of  copper,  the  other  of  zinc, 
stiffly  and  completely  isolated  from  such  other  by  being  set  in  a  hard- 
rubber  frame.  Two  insulated  wires  are  connected,  one  with  the  zinc 
plate,  the  other  with  the  copper.  The  probe  itself  is  a  metal  contain- 
ing the  continuations  of  the  wires  just  mentioned.  The  tip  of  the 
probe  is  isolated  from  the  shank  by  a  hard-rubber  washer.  The  tip 
consists  of  two  or  four  (or  other  even  numbers)  bright  metallic  pieces 
separated  from  each  other  by  thin  hard-rubber  or  similar  material,  and 
connected  with  the  insulated  wires  in  the  probe.  These  hidden  wires 
lie  loosely  in  the  probe-shank,  so  that  it  may  be  bent  in  any  way  with- 
out putting  them  on  the  stretch.  They  are  firmly  fixed  to  a  plug  in 
the  near  end  of  the  shank,  so  that  they  cannot  be  drawn  tight.  From 
this  plug  emerge  two  connecting  pins  to  which  the  wires  from  the 
mouth-piece  are  to  be  attached. 

"  When  the  operator  holds  the  mouth-piece  in  position  by  closing  the 
teeth  upon  it,  nothing  is  perceived  until  the  electrodes  in  the  probe  end 
touch  metal,  when  an  immediate,  contimious,  and  unmistakable  sensa- 
tion, together  with  metallic  taste,  is  experienced.  No  contact  except 
a  metallic  one  will  produce  this  phenomenon,  the  current  engendered 
by  the  mouth-battery  being  too  weak  to  be  appreciated  until  this 
battery  is  short-circuited. 

"  The  probe-end  may  be  made  of  various  shapes,  giving  more  or  less 
opportunity  for  double  contact.  It  is  found,  however,  that  for  a  small 
button  two  electrodes  are  sufficient,  while  for  a  large  button  four  or 


INJURIES  AND   DISEASES   OF   THE   HEAD.  485 

more  may  be  of  advantage.  A  slight  rotation  of  the  shank,  whether 
it  be  straight  or  curved,  will  usually  suffice  to  establish  double  contact. 
The  shank  is  made  of  thick-walled,  flexible-metal  tubing,  but  it  should, 
not  be  bent  too  near  the  end,  for  fear  of  breaking  the  button.  The 
probe-shank  may  also  be  made  wholly  or  in  part  of  flexible  material ; 
for  example,  jointed  metal,  or,  still  better,  woven  catheter  material 
(silk  or  linen). 

"  The  probe  may  be  improvised  as  follows  :  Cut  both  ends  off  a  soft 
catheter.  Take  two  pieces  of  wire  and  insulate  them  to  within  an  inch 
of  their  ends  by  wrapping  round  each  wire  a  layer  of  gutta-percha 
tissue  and  then  warming,  or  even  by  winding  the  wire  with  adhesive 
plaster.  Run  the  wires  through  the  catheter,  allowing  the  two  ends  to 
project  at  the  proximal  end.  Two  short  ones,  each  bent  on  itself  so 
that  a  smooth  loop  of  wire  may  present,  instead  of  a  rough  cut  end, 
should  project  at  the  distal  end.  A  drop  of  hot  sealing-wax  at  each 
end  fixes  the  wires  to  the  catheter  and  isolates  them  firmly  from  each 
other.  The  long  ends  of  the  wire  are  now  wound  tightly  around  two 
coins,  the  one  around  the  copper,  the  other  around  the  silver  piece, 
previously,  of  course,  removing  as  much  as  necessary  of  the  gutta- 
percha insulation.  Entirely  cover  these  connections  with  sealing-wax. 
This  probe  will  now  work  well  enough  for  an  emergency,  but  the  dan- 
ger of  short-circuiting  in  an  improvised  probe  must  be  borne  in  mind. 
Short-circuiting  in  the  probe  made  by  the  instrument-maker  is  hardly  a 
possibility. 

"  With  this  instrument  I  performed  the  following  experiment :  Fiv^e 
shots  were  fired  into  a  piece  of  raw  beef,  the  bullets  passing  through 
a  tough  fascia,  through  two  layers  of  muscle,  and  to  or  into  bone 
beyond.  Four  of  the  bullets  (22  caliber)  were  easily  found.  The 
fifth  eluded  my  search,  but  section  showed  that  the  ball  had  bounded 
back  from  the  bone,  making  a  channel  almost  parallel  with  the  one  of 
entrance.  The  probe,  therefore,  never  came  in  contact  with  the  pro- 
jectile." 

A  most  painstaking  search  sometimes  fails  to  find  the  bullet.  In 
that  case  a  drainage-tube  should  be  passed  into  the  wound  for  its  entire 
length,  and  thorough  asepsis  maintained  during  the  process  of  healing. 

Besides  bullets,  other  foreign  bodies  occasionally  driven  into  the 
brain  are  portions  of  clothing,  pieces  of  bone,  bits  of  wood,  hair,  etc. 
These  are  almost  certain  to  carry  septic  germs  with  them,  and  on  that 
account  should  be  removed  at  the  earliest  possible  moment. 

VII.   SEPTIC   INFLAMMATION  WITHIN   THE  CRANIUM. 

Septic  germs  may  gain  access  to  the  brain  and  its  membranes  by 
any  of  the  following  routes  : 

1.  Through  the  orbital  cavity,  because  of  the  extensions  of  the 
subdural  and  arachnoid  spaces  along  the  optic  nerve.  Every  suppu- 
ration in  the  orbital  cavaty  or  within  the  eyeball  has  a  tendenc}'  to 
spread  to  the  brain. 

2.  Through  the  nose.  Septic  infection  in  the  nose  may  spread  to 
the  frontal  and  ethmoid  sinuses,  and  through  the  naso-pharynx  it  may 
infect  the  ear. 


486  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

3.  \\y  the  car.  Suppuration  in  the  niicklle  ear,  especially  when  the 
tympanum  is  destroyed,  finds  its  way  readily  into  the  brain,  and  pro- 
duces more  brain-abscesses  than  all  other  causes  combined.  Fracture 
of  the  base  of  the  skull  involving  the  petrous  portion  of  the  temporal 
bone  is  for  this  reason  a  compound  fracture,  and  must  be  treated 
as  such. 

4.  Along  the  vessels  which  pass  through  the  skull  and  form  com- 
munications with  the  scalp  and  other  soft  parts  without,  and  the  brain 
and  its  membranes  within,  the  cranium.  Hence  it  is  that  a  simple  scalp 
wound  (if  dressed  without  aseptic  care)  or  an  attack  of  erysipelas  of 
the  scalp  may  be  followed  by  meningitis  or  cerebral  abscess. 

Inflammation  of  the  Brain  and  its  Membranes. — It  is  impos- 
sible to  diagnosticate  with  certainty  inflammation  of  the  membranes  from 
inflammation  of  the  brain  itself  The  following  diseases  may  be  recog- 
nized on  the  post-mortem  table,  but  not  clinically :  Inflammation  of  the 
dura  mater — pacJiynicningitis  ;  inflammation  of  the  pia  and  arachnoid — 
Icptovicningitis  ;  inflammation  of  the  cerebrum — ccrcbritis ;  inflamma- 
tion of  the  cerebellum — ccrcbcllitis. 

In  every  case  of  fracture  of  the  skull  or  other  severe  traumatism 
of  the  head,  and  in  all  cases  of  suppuration  in  the  orbit,  the  nose,  or 
the  middle  ear,  the  onset  of  symptoms  which  indicate  inflammation  of 
the  brain  or  its  membranes  should  be  carefully  watched  for. 

Syviptouis. — After  an  injury  which  causes  primary  meningitis,  such 
as  compound  fracture  of  the  skull,  the  first  symptom  may  set  in  as 
early  as  the  end  of  twenty-four  or  thirty-six  hours.  In  other  cases  the 
evidence  of  encephalitis  will  appear  when  the  septic  infection  reaches 
the  membranes.  The  first  warning  symptom  is  generally  a  chill,  fol- 
lowed by  a  rapidly  rising  temperature. 

{a)  Nervous  Symptoms. — There  is  from  the  first  malaise,  then  rest- 
lessness, increasing  to  such  an  extent  that  the  patient  becomes  uncon- 
trollable. Headache  is  present,  and  often  intense,  and  there  is  intoler- 
ance of  light  and  sound.  Delirium  follows,  which  after  a  variable 
length  of  time  is  succeeded  by  quiet  and  consciousness. 

{b)  Febrile  Symptoms. — The  temperature  rises  rapidly  and  reaches 
103°  or  104°  F.  The  pulse  at  first  is  full  and  bounding,  but  afterward 
becomes  small  and  weak.  The  eyes  are  red  and  congested.  Consti- 
pation is  an  early  and  constant  symptom. 

{c)  Pressure-symptoms. — Ptosis  may  be  taken  as  an  indication  that 
the  third  nerve  is  suffering  pressure  at  its  origin  or  along  its  course ; 
dilatation  of  the  pupils,  external  strabismus,  and  loss  of  power  of 
accommodation  would  be  further  evidence  of  an  affection  of  this 
nerv^e.  Incontinence  of  urine  is  common  in  the  early  stages,  and 
retention  at  a  late  period.  Paralysis  of  the  tongue,  loss  of  hearing, 
diplopia,  etc.  are  indications  of  extension  of  the  disease  along  the  base 
of  the  brain. 

Differential  Diagnosis. — Pyemia  may  closely  simulate  encephalitis. 
Pyemia,  however,  does  not  set  in  before  the  end  of  the  first  week, 
while  primary  encephalitis  usually  occurs  about  the  second  or  third 
day.  Pyemia  is  also  attended  with  more  frequent  and  pronounced 
chills  than  encephalitis. 

Uremic  coma  is  distinguished  from  encephalitis  by  the  presence  of 


INJURIES  AND  DISEASES   OF   THE   HEAD.  487 

albumin  and  tube-casts  in  the  urine  and  by  albuminuric  retinitis. 
There  is  also  edema  of  the  feet  and  ankles ;  chills  are  usually  wanting. 

Treatinent. — The  patient  should  be  kept  in  a  darkened  room  and  as 
quiet  as  possible.  The  bowels  should  be  freely  moved,  but  not  to  the 
extent  of  causing  severe  purgation.  The  head  should  be  shaved  and 
cold  applied  in  the  form  of  ice-bags  or  cold-water  coil.  During  the 
stage  of  delirium  the  bladder  should  be  emptied  by  the  catheter  at 
regular  intervals.  For  the  nervous  excitement  hydrobromate  of 
hyoscin,  gr.  y^,  is  one  of  the  best  remedies,  care  being  taken  not  to 
push  it  so  far  as  to  obtain  its  toxic  effects.  Bromid  of  potassium  is 
also  an  excellent  sedative,  and  can  be  given  in  doses  of  thirty  grains 
three  times  a  day  if  necessary.  Blisters  to  the  nape  of  the  neck  and 
iodid  of  potassium  internally  are  indicated  when  pressure-symptoms 
supervene.  During  convalescence,  should  such  be  the  fortunate  ter- 
mination of  the  case,  mental  exertion  should  be  avoided  for  many 
weeks. 

The  question  of  trephining  for  the  relief  of  suppurative  inflammation 
of  the  brain  or  its  membranes  is  one  involving  considerable  difficulty. 
On  the  broad  surgical  principle  that  pus  should  be  evacuated  and  the 
cavity  drained  it  would  be  clearly  our  duty  to  trephine,  incise  the  dura, 
and  drain  in  every  case  of  suppuration  of  the  encephalon.  This,  how- 
ever, has  not  become  an  established  usage.  If  the  location  of  the  dis- 
eased area  can  be  made  out  by  the  existence  of  focal  symptoms  as 
definite  as  we  find  them  in  cerebral  hemorrhage,  for  instance,  there 
cannot  be  a  doubt  that  the  duty  of  the  surgeon  is  to  trephine  over 
the  area  indicated  and  drain  the  suppurating  part.  The  results  are 
much  more  promising  when  the  convexity  of  the  brain  is  involved 
than  when  the  base  is  the  seat  of  the  lesion. 


VIII.   ABSCESS  OF  THE   BRAIN. 

We  should  go  far  astray  if  we  attempted  to  diagnosticate  abscess  of 
the  brain  by  the  symptoms  which  mark  the  course  of  abscesses  in 
other  parts  of  the  body.  For  instance,  a  brain-abscess  may  not  present 
any  symptoms  until  weeks,  months,  or  even  years  after  the  injury 
which  was  its  direct  cause.  The  body-temperature  is  high  in  ordinary 
abscess,  but  in  cerebral  collections  of  pus  the  temperature  is  normal  or 
subnormal.  The  pulse,  instead  of  rising  to  100  or  120,  falls  to  60,  40, 
or  even  30  beats  per  minute.  The  disease,  however,  is  marked  by 
very  pronounced  symptoms,  and  can  in  most  cases  be  differentiated 
from  other  intra-cranial  lesions. 

The  situations  of  abscess  are  practically  the  same  as  those  of  intra- 
cranial hemorrhage — viz.  extradural,  subdural,  cerebral,  and  cerebellar. 

Causes. —  i.  Suppuration  in  the  middle  ear.  This  is  the  cause  of 
about  50  per  cent,  of  all  cases.  It  has  always  been  supposed  that 
acute  inflammation  of  the  ear  seldom  leads  to  brain-disease,  but  recent 
epidemics  of  influenza  have  shown  that  such  is  not  uncommon. 
Chronic  suppuration  is  always  attended  with  danger.  Between  the 
tympanum  and  the  middle  fossa  of  the  base  of  the  skull  is  only  a  thin 
bony  partition.  When  the  mucous  membrane  is  destroyed  and  the 
bone  laid  bare,  disease  can  readily  break  through  this  thin  plate  and 


488  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

produce  innaniiiiation  of  the  membranes,  abscess  of  the  temporo- 
sphenoidal  lobe  or  cerebellum,  or  thrombosis  of  the  petrosal  or  lateral 
sinus. 

2.  Punctured  wounds  of  the  sqalp  extending  to  the  bone,  exposing 
and  bruisin<;  the  skull  over  a  small  area.  The  instruments  causing 
such  wounds  usually  carry  infective  matter  with  them.  The  bone  once 
infected,  thrombosis  of  the  veins  of  the  diploe  follows,  whence  the  in- 
fection is  carried  along  the  perivascular  sheaths  to  the  brain.  It  is  this 
danger  which  renders  the  treatment  of  small  scalp  wounds  so  important. 
The  wound  may  heal  externally  by  first  intention,  and  the  patient  may 
forget  about  his  accident  and  follow  his  daily  occupation,  until,  weeks 
or  months  afterward,  cerebral  symptoms  begin  to  appear. 

3.  Punctured  fractures  are  still  more  dangerous,  as  the  infective 
material  may  be  carried  through  the  skull  into  the  brain  itself. 

4.  Compound  fracture  of  the  skull,  provided  the  wound  is  large  and 
drainage  free,  is  not  likely  to  be  followed  by  cerebral  abscess.  Fissures 
of  the  skull  are  dangerous  from  the  fact  that  there  may  be  infection 
between  the  edges  of  the  fractured  bone.  Such  a  wound  cannot  be 
cleaned  by  sponging  or  irrigation.  The  chisel  alone  is  sufficient,  and 
the  best  course  is  to  remove  a  V-shaped  portion  along  the  line  of 
the  fissure. 

5.  Contusion  of  the  skull  without  fracture  is  occasionally,  a  cause  of 
cerebral  abscess,  but  there  is  always  an  infection  of  the  bone  which 
finds  its  way  to  the  membranes  and  brain  by  the  vascular  connections. 

6.  Necrosis  of  the  skull  not  infrequently  leads  to  the  formation  of 
an  extradural  abscess,  which,  if  not  relieved,  is  apt  to  extend  to  the 
cerebi-al  tissue. 

7.  Erysipelas  and  other  infective  conditions  of  the  face  and  scalp 
are,  especially  in  aged  people,  causes  of  cerebral  abscess.  Here,  again, 
the  method  of  infection  is  thrombosis  of  the  veins  and  conveyance  of 
the  streptococci  to  the  intra-cranial  tissues. 

Symptoms. — As  quite  50  per  cent,  of  cases  are  due  to  suppuration 
of  the  middle  ear,  the  symptoms  as  they  occur  in  this  class  of  cases 
will  first  occupy  our  attention.  For  a  more  exhaustive  study  of  the 
subject  I  would  refer  the  reader  to  the  excellent  work  of  Macewen,  to 
which  I  am  indebted  for  much  that  follows.  It  is  convenient  to  divide 
the  disease  into  three  stages:  (i)  the  initiatory,  (2)  the  fully-formed 
abscess,  (3)  the  terminations  when  uninterrupted  by  treatment. 

The  Initiatory  Stage. — There  is  a  history  of  chronic  suppurative 
disease  of  the  middle  ear,  or  one  of  the  traumatisms  already  described, 
or  suppurative  disease  of  the  nose,  mouth,  or  orbit.  The  otitis  may 
have  lasted  many  weeks  or  months,  and  may  have  caused  little  pain  or 
inconvenience,  when  suddenly,  after  exposure  to  cold  or  after  a  blow  or 
fall  upon  the  head,  or  even  without  apparent  cause,  the  patient  becomes 
ill  and  the  symptoms  point  to  the  brain. 

Pain  is  first  felt  in  the  ear,  and  is  described  as  burning  or  shooting 
in  character.  From  the  ear  it  soon  spreads  to  the  temporal  region, 
and  after  twenty-four  hours  to  the  frontal  and  occipital  areas.  This 
diffusion  of  the  pain  must  not  be  permitted  to  mislead  the  surgeon, 
for  even  when  abscess  is  in  the  cerebellum  the  pain  is  often  felt  in  the 
forehead  (Macewen).     In  fact,  in  all  head-affections  the  location  of  pain 


INJURIES  AND  DISEASES   OF   THE   HEAD. 


489 


is  of  very  little  diagnostic  value.  Sometimes  the  pain  darts  through 
the  head  from  ear  to  ear.  The  pain  often  resembles  severe  neuralgic 
attacks,  with  intervals  in  which  it  is  dull  and  aching.  Rigors  are  often 
described  by  the  patient's  friends  as  convulsions,  and  care  must  be 
taken  to  differentiate  between  the  two.  Most  cases  begin  with  a  rigor, 
just  as  we  find  in  abscesses  m  other  situations.  The  intensity  of  the 
chill  varies  greatly.  In  one  case  there  may  be  a  sHght  sensation  of 
cold,  in  another  a  violent  and  prolonged  shaking. 

Vomiting  is  a  common  symptom  and  may  be  free  from  nausea. 

The  temperature  in  this  early  stage  is  slightly  elevated  and  the  pulse 
is  increased  in  frequency. 

The  discharge  of  pus  from  the  ear  usually  stops,  and  leads  the 
laity  into  the  belief  that  this  stoppage  is  the  cause  of  the  whole  trouble. 

Second  Stage. — The  first  or  initiatory  stage  was  attended  with 
intense  pain,  increased  temperature,  rapid  pulse.  The  second  stage 
shows  the  reverse.  Pain  over  the  ear  may  still  be  complained  of,  but 
the  violent  diffused  pain  is  no  longer  present.     The  patient's  sensibility 


George  S 

/Et  21  Years.     Admitted  May  14th.                On  21st.  Day  of  Disease. 

Day  OF  Illness 

106° 

105° 
104° 

2 1ST. 

2C-.P. 

23HP, 

24TH 

25TH. 

2GTH. 

27TH. 

28TH. 

3b'.<  l-J  3>)'.i  VI 

^^ 



- 

— 

rj 

, 

5           102 

cc              . 
UJ           101 

LU           100 

39° 

98° 

97° 

E=^-^ 

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^. 

-J 

g. 

!-A. 

&:^. 

TT-^ r 

t— 

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-.=.^ 

..i, 

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■  :::-;-= 

Fig.  212. 


-Abscess  of  the  brain  :  temperature-chart  of  a  typical  uncomplicated  case 
(Macewen). 


is  blunted  because  there  is  encephalitis,  and  the  pain  is  really  less  on 
account  of  increased  pressure  and  reduction  of  mental  perception. 
Two  very  characteristic  symptoms  mark  this  stage :  one  is  pain  on 
pressure  over  the  mastoid  process  and  the  squamous  portion  of  the 
temporal  bone  on  the  affected  side.  The  other  symptom  is  delayed 
cerebration.  When  asked  a  question  the  patient  stares  vacantly  and 
makes  no  immediate  reply.  The  answer  comes,  however,  after  a  brief 
interval,  and  is  given  in  a  slow,  concise,  dignified  manner,  and  generally 
correct.  Following  this,  or  coincident  with  it,  is  a  condition  veiy 
similar  to  that  which  is  produced  by  opium  in  large  doses.  The 
patient  is  unable  to  sustain  his  attention.  In  giving  an  answer  which 
requires  a  number  of  sentences  he  gets  lost  in  the  middle,  and  is  either 
asleep  or  has  forgotten  what  he  was  talking  about  before  his  answer  is 
finished.  If  he  asks  for  something,  he  forgets  all  about  it  before  his 
request  is  granted.  Another  characteristic  of  the  mental  condition  is 
inability  to  apply  the  strength.  He  may  be  quite  able  to  perform  an  act, 
but  the  will-power  is  wanting — a  condition  very  familiar  to  those  who 
have  frequently  taken  opiates. 


490 


SUKG/C.iL    DIAGNOSIS  AND    TREATMENT. 


Fig.  213. — Chart  of  infective  thrombosis  of  cavernous  sinus,  for  comparison  with  that  of 
cerebral  abscess  (Macewen). 

The  temperature  in  the  second  stage  is  normal  or  subnormal ;  its 
average  range  may  be  set  down  at  97°  to  99°  F. 

Figs.  212,  213,  214  illustrate  the  difference  in  temperature  between 


Fig.  214. — Chart  of  infective  purulent  cerebro-spinal  leptomeningitis  (Macewen), 


INJURIES  AND  DISEASES   OE   THE  HEAD.  49 1 

cerebral  abscess,  infective  thrombosis,  and  cerebro-spinal  leptomenin- 
gitis. 

The  pulse  also  falls  below  normal,  and  may  beat  sixty,  forty,  or  even 
thirty  times  in  the  minute.  A  slow  pulse  with  a  high  temperature 
indicates  intra-cranial  disease ;  when  pulse  and  temperature  are  both 
high,  it  points  to  systemic  disease.  A  slow  pulse  is  produced  by  pres- 
sure on  the  brain.  It  is  found  in  abscess,  in  extradural  blood-clots  and 
intra-cranial  tumors.  The  respirations  are  diminished  in  frequency,  and 
may  assume  the  Cheyne-Stokes  character.  This  is  especially  the  case 
when  the  abscess  is  in  the  cerebellum.  Other  symptoms  more  or  less 
constant  in  this  stage  of  cerebral  abscess  are  constipation,  vomiting, 
convulsions,  rigors,  and  optic  neuritis. 

Third  Stage. — If  allowed  to  take  its  course,  cerebral  abscess  usually 
ends  in  death.  The  patient  may  pass  into  a  stage  of  profound  stupor 
and  die  of  coma.  The  abscess  may  rupture  either  upon  the  surface  of 
the  brain,  and  its  contents  spread  over  the  convexity  of  the  cerebrum, 
or  it  may  burst  into  the  ventricles,  in  either  of  which  events  a  train  of 
symptoms  is  produced  whose  universal  termination  is  death.  Spread- 
ing over  the  brain-surface,  acute  leptomeningitis  is  produced,  and  we 
recognize  this  new  departure  by  the  onset  of  rapid  pulse  and  high  tem- 
perature, vomiting,  restlessness,  squinting,  flushing  of  the  face,  and 
spasmodic  contractions  of  the  muscles.  When  the  abscess  ruptures 
into  the  ventricles,  a  sudden  and  alarming  change  takes  place  in  the 
patient's  condition.  The  pupils  dilate  widely,  the  face  becomes  livid, 
and  the  breathing  hurried,  shallow,  or  stertorous.  The  temperature 
rises  rapidly  to  103°,  104°,  or  105°,  and  the  pulse  comes  up  with  a 
bound  from  40  or  50  to  120.  Convulsions  are  common,  and  the  end 
may  be  expected  in  six  to  twelve  hours  from  the  time  of  rupture. 

Besides  the  general  symptoms  just  described,  the  situation  of  a 
cerebral  abscess  may  be  definitely  determined  by  localizing  symptoms. 
Arising  from  suppurative  ear-disease,  the  abscess  is  usually  in  the  tem- 
poro-sphenoidal  lobe  or  the  cerebellum,  which  are  both  remote  from 
the  motor  area,  but  even  then  large  abscesses  may  exert  pressure  upon 
the  motor  centers.  When  the  abscess  is  in  the  frontal  or  temporo- 
sphenoidal  lobe,  the  pupil  on  the  same  side  may  show  any  of  the 
following  conditions :  i.  Contracted  and  stable:  this  indicates  a  slight 
degree  of  compression  and  a  small  abscess ;  2.  Dilated  and  stable : 
indicating  a  greater  degree  of  pressure  and  a  large  abscess. 

When  there  is  sufficient  pressure  upon  the  third  nerve  to  cause  par- 
alysis there  are  ptosis,  external  strabismus,  and  a  fixed,  dilated  pupil  of 
the  same  side. 

Hemiplegia  of  the  opposite  side  is  observed  in  large  abscesses. 
Aphasia  is  sometimes  produced.  Motor  aphasia  suggests  pressure  on 
Broca's  convolution  ;  sensory  aphasia  or  word-deafness,  the  posterior 
half  of  the  first  temporal  convolution. 

Abscess  of  the  occipital  lobes  is  a  rare  affection  and  is  generally 
pyemic. 

Abscess  of  the  cerebelhun  is  attended  with  great  prostration,  feeble 
pulse  and  respiration,  and  low  temperature.  Certain  muscular  phe- 
nomena are  sometimes  observed ;  these  are  retraction  of  the  head 
and  neck  and  rigidity  of  the  masseters,  causing  firm  closure  of  the 


492  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

mouth,  ^^'^\vnin<,f  is  coniiiion,  and  speech  when  attempted  is  slow  and 
jerk\-. 

Differential  Diagnosis. — In  the  earl)-  staf,^e  it  is  impossible  to  dif- 
ferentiate cerebral  abscess  from  meningitis  or  acute  encephalitis.  In  fact, 
at  this  stage  the  diseases  are  coincident,  the  abscess  being  surrounded 
by  an  inllamed  zone  of  brain-tissue.  Rigors  occurring  in  the  course 
of  encephalitis  should  cause  suspicion  of  abscess.  Time  is  an  import- 
ant factor  in  diagnosis.  Meningitis  develops  within  three  or  four  days, 
while  abscess  seldom  appears  before  the  end  of  a  week!  The  onset  of 
meningitis  is  also  more  abrupt,  and  is  attended  with  delirium,  high 
temperature,  photophobia,  and  contractions  of  both  pupils  simul- 
taneously ;  in  abscess  only  one  pupil  is  affected,  and  that  on  the 
side  in  which  the  abscess  is  situated. 

Thrombosis  of  tJic  Lateral  Simts. — In  this  condition  the  temperature 
is  high,  and  the  jugular  vein  is  felt  to  be  hard  and  knotted,  for  the 
thrombus  which  occludes  the  lateral  sinus  also  extends  into  the  inter- 
nal jugular.  Respirations  arc  quickened  and  vomiting  occurs  when  the 
patient  is  in  the  upright  position.  Pyemic  symptoms  develop  at  a  later 
period,  and  w^hen  abscesses  appear  in  the  lungs  and  joints  there  can  be 
no  room  for  doubt. 

Tumor  of  the  brain  is  distinguished  from  abscess  by  the  slow 
development  of  the  symptoms.  Febrile  symptoms  are  wanting,  nor 
is  there  a  history  of  an  injury  or  a  suppuration  which  could  be  the 
source  of  infection.  The  localizing  symptoms  in  the  case  of  tumors 
are  more  definite  than  in  abscess,  and  optic  neuritis  is  more  constant 
and  pronounced. 

An  error  to  be  carefully  guarded  against  is  the  mistaking  of  a 
cerebral  abscess,  spreading  from  the  middle  ear  through  the  tegmen, 
for  disease  in  the  mastoid  cells.  It  has  repeatedly  happened  that  the 
surgeon  has  opened  the  mastoid  cells  without  benefit,  the  disease  going 
on  to  a  fatal  termination,  and  a  post-mortem  examination  showing  that 
the  suppuration  had  spread  through  the  tegmen,  causing  meningitis  or 
abscess  (Crafts). 

Treatment. — Prophylactic. — There  are  few  diseases  in  which  so 
much  can  be  done  in  the  way  of  prevention  as  in  abscess  of  the  brain. 
A  wound  of  the  scalp,  be  it  ever  so  small,  should  be  treated  with  the 
utmo.st  aseptic  care.  Too  often  such  cases  are  rushed  to  the  nearest 
drug-store,  the  blood  washed  off  with  an  unclean  sea-sponge  and  germ- 
laden  water,  a  few  locks  of  hair  cut  away  with  scissors,  and  an  artistic 
stellate  patch  of  sticking-plaster  applied  to  the  wound.  Suppuration  is 
inevitable,  and  the  risk  of  septic  infection  ever  present.  In  scalp-wounds 
and,  a  fortiori,  in  compound  fractures,  the  scalp  should  be  shaved  for 
a  considerable  distance  around  the  seat  of  injury  ;  dirt  should  be  washed 
off  with  soap  and  water,  and,  if  a  flap  of  the  scalp  is  so  impregnated 
that  the  dirt  cannot  be  washed  away,  it  should  be  removed  with  a 
sharp  knife,  so  as  to  leave  a  freshened  surface.  Ether,  alcohol,  or  tur- 
pentine should  next  be  used,  and  afterward  a  solution  of  corrosive  sub- 
limate, I  :  2000.  If  a  fissured  fracture  of  the  vault  holds  in  its  grasp 
hair  or  other  sources  of  infection,  a  V-shaped  channel  should  be  chis- 
elled out,  removing  the  lips  of  the  outer  and  leaving  the  inner  table  of 
the  skull.     If  the  surface  of  the  bone,  without  being  fractured,  has  dirt 


INJURIES  AND  DISEASES   OF  THE  HEAD.  493 

ground  into  it  which  cannot  be  washed  out,  the  surface  should  be  chis- 
elled off. 

When  the  dura  mater  or  the  brain  has  been  infected  in  compound 
fractures,  the  dura  should  be  freely  incised  and  carefully  disinfected. 
Fractures  of  the  base  or  punctured  fractures  made  by  way  of  the  orbit, 
the  nose,  or  the  mouth  should  be  kept  from  infection  by  constant  dis- 
infection of  the  cavities,  as  also  the  cavity  of  the  ear.  Chronic  suppura- 
tion of  the  middle  ear  should  be  looked  upon  as  a  constant  source  of 
danger  and  treated  accordingly. 

Abscess  of  the  brain  is  almost  invariably  fatal  unless  means  be 
taken  to  evacuate  the  pus  and  drain  the  abscess-cavity.  The  recent 
advances  in  brain-surgery  have  placed  the  operation  of  trephining  for 
abscess  on  a  sound  basis,  and  many  successful  cases  have  been  re- 
ported. The  localizing  symptoms  must  be  mainly  relied  upon  to 
determine  the  position  for  the  opening  in  the  skull.  If  a  scar  is  pres- 
ent and  the  local  symptoms  indicate  that  the  abscess  is  beneath  the 
scar,  the  trephine  should  be  applied  there.  If,  on  the  other  hand,  the 
localizing  symptoms  point  to  some  other  part  of  the  brain  as  the  seat 
of  abscess,  the  position  of  the  scar  should  be  disregarded. 

The  preparation  of  the  patient  and  the  mode  of  opening  the  skull 
have  already  been  described.  Macewen  suggests  that  the  exposed 
osseous  surface  made  by  the  trephine  be  rubbed  over  with  iodoform 
and  boracic-acid  powder  to  protect  the  bone  from  contamination  by  the 
pus  about  to  be  withdrawn. 

On  opening  the  dura  mater  the  brain-substance  will  bulge  up  into 
the  wound,  and  if  the  pressure  be  great  the  normal  pulsations  will  be 
wanting.  The  best  instrument  for  exploring  the  brain  is  an  ordinary 
grooved  director.  It  is  pushed  gently  into  the  cerebral  substance  at 
right  angles  to  the  surface  and  in  the  direction  in  which  the  collection 
of  pus  is  supposed  to  lie.  When  the  cavity  is  reached,  the  operator  is 
warned  of  the  fact  by  a  sense  of  lessened  resistance  and  by  the  appear- 
ance of  pus  in  the  groove  of  the  instrument.  Should  the  first  attempt 
fail,  the  director  is  to  be  withdrawn  and  passed  in  another  direction, 
nothing  being  done  which  will  change  the  puncture  to  a  laceration  of 
the  brain-substance.  When  pus  is  found  a  fine  straight  knife  is  passed 
along  the  director,  and  an  opening  made  sufficient  to  admit  a  pair  of 
hemostatic  forceps.  The  latter  instrument  is  then  passed  into  the 
abscess,  moderately  opened  and  withdrawn,  so  as  to  dilate  the  incision 
made  by  the  knife.  The  granulation-tissue  lining  the  cavity  is  next 
carefully  and  gently  scraped  away  with  a  spoon  and  the  cavity  washed 
out  with  boric-acid  solution.  A  rubber  drainage-tube  is  passed  down 
to  the  bottom  of  the  cavity  and  made  to  emerge  through  an  opening  in 
the  scalp,  to  which  it  is  attached  by  a  stitch.  The  bone  is  not  replaced. 
A  moist  dressing  is  applied.  At  the  end  of  forty-eight  hours  the  tube 
is  shortened  from  day  to  day  until  it  is  no  longer  required.  It  must  be 
borne  in  mind  that  suppuration  is  apt  to  recur,  and  this  may  be  months 
and  even  years  after  apparent  healing.  On  this  account  the  drainage- 
tube  should  not  be  removed  too  early.  It  must  be  remembered,  too, 
that  drainage-tubes  do  not  act  so  effectually  here  as  elsewhere ;  an 
abscess  once  evacuated,  the  walls  of  the  cavity  rapidly  come  into  con- 
tact with  each  other  as  a  result  of  pressure  in  the  neighboring  areas. 


494  SURGICAL  DIAGNOSIS  AND    TREATMENT. 

In  this  way  it  is  easy  for  septic  germs  to  be  retained  instead  of  coming 
away  with  the  drainage,  and  such  germs,  remaining  latent  for  a  time, 
may  result  in  abscess  at  a  remote  period. 

Abscess  of  the  cerebellum  is  best  reached  by  a  trephine  opening 
made  just  below  the  position  of  the  lateral  sinus — that  is  to  say,  below 
a  line  leading  from  the  external  auditory  meatus  to  the  external  oc- 
cipital protuberance.  The  proper  point  on  this  line  is  one  midway 
between  the  tip  of  the  mastoid  process  and  the  inion.  Abscess  in  the 
frontal  lobes  is  reached  either  from  the  temporal  region  or  from  the 
front  of  the  brow  according  to  the  position  of  the  abscess.  If  the  pus 
is  contained  in  the  posterior  part  of  the  lobe,  it  is  best  reached  from  the 
temple,  but  at  the  same  time  there  is  a  danger  that  after  going  through 
the  temporal  muscle  suppuration  may  take  place  beneath  it,  the  part 
being  infected  from  the  abscess.  By  the  frontal  route  the  danger  is  that 
the  frontal  sinus  may  be  opened  into.  In  cases  which  involve  the  sinus 
itself  this  opening  is  a  necessity.  To  expose  the  cribriform  plate  of  the 
ethmoid  a  small  opening  may  be  made  a  quarter  of  an  inch  above  the 
glabella,  "  remembering  that  the  frontal  lobes  dip  at  this  point  to  the 
level  of  the  nasion  "  (Macewen). 

When  the  cerebral  abscess  is  a  result  of  disease  in  the  middle  ear 
the  first  procedure  in  an  operative  way  is  the  opening  of  the  mastoid 
process  and  its  thorough  cleansing.  A  vertical  incision  two  inches  in 
length  is  made  a  quarter  of  an  inch  behind  the  external  auditory 
meatus,  beginning  at  the  posterior  root  of  the  zygoma  and  ending  a 
third  of  an  inch  from  the  tip  of  the  mastoid  process.  The  incision  is 
made  down  to  the  bone,  and  the  periosteum  and  soft  parts  are  separated 
forward  so  as  to  expose  fully  the  external  auditory  meatus.  This  flap, 
including  the  auricle,  is  held  forward  by  a  sharp  retractor,  and  bleeding 
points,  if  any,  are  stopped. 

At  this  stage  Macewen  recommends  attention  to  the  three  following 
points  :  "  First,  the  position  of  the  suprameatal  triangle — a  triangle 
formed  by  the  posterior  root  of  the  zygoma  above,  the  upper  and 
posterior  segment  of  the  osseous  external  meatus  below,  and  an 
imaginary  line  uniting  these  two  extending  from  the  most  posterior 
portion  of  the  external  osseous  meatus  to  the  zygomatic  root  (Figs. 
215,  216).  Within  this  triangle  and  touching  its  base  the  opening  into 
the  mastoid  antrum  is  made  with  safety.  Second,  the  degree  of 
obliquity  of  the  posterior  osseous  wall  of  the  external  auditory  meatus, 
as  w^hen  this  wall  is  directed  more  obliquely  from  behind  forward,  the 
mastoid  antrum  is  situated  slightly  more  anteriorly  than  when  the 
osseous  wall  of  the  meatus  is  directed  more  transversely  from  without 
inward.  Third,  the  depth  of  the  inner  wall  of  the  tympanic  cavity 
from  the  level  of  the  skull  at  the  osseous  portion  of  the  external  audi- 
tory meatus,  which  may  be  determined  by  introducing  a  probe  through 
the  external  ear  till  it  comes  gently  in  contact  with  the  inner  wall  of 
the  tympanum,  the  membrane  having  been  previously  perforated  by 
pathological  processes,  and  then  marking  on  it  the  limit  of  the  outer 
aspect  of  the  osseous  meatus.  If  the  middle  ear  lie  deep,  the  mastoid 
antrum,  which  is  more  superficial,  may  be  expected  to  be  relatively 
deeply  seated."  ^     The  opening  into  the  antrum  is  made  slightly  forward 

^  Diseases  of  Br  am  and  Spinal  Cord,  p.  297. 


INJURIES  AND  DISEASES   OF  THE  HEAD. 


495 


to  avoid  the  sigmoid  sinus.     At  the  depth  of  half  an  inch  Hes  the 
facial  nerve,  and  this  must  be  avoided,  twitching  of  the  facial  muscles 


Fig.  21! 


—Schema   of  squamo-mastoid  portion  of   the  temporal,  showing  the  suprameatal 
triangle  in  relation  to  the  sigmoid  groove  and  facial  nerve  (Macewen). 


Fig.  2i6. — Surface  guides  for  the  sigmoid  sinus  and  the  suprameatal  triangle  (Macewen), 
artificial  lines  drawn  upon  the  skull  indicating  the  following  :  (i)  The  short  vertical  line  from 
the  posterior  border  of  the  external  auditory  meatus  to  the  posterior  root  of  the  zygoma  marks 
the  base  of  the  suprameatal  triangle  (a)  ;  the  broken  line  indicates  the  anterior  border  of  the 
suprameatal  triangle,  its  base  being  the  dotted  line  marking  a  part  of  the  root  of  the  zygoma. 
This  broken  line  also  indicates  the  course  of  the  facial  nerve.  (2)  The  second  vertical  line, 
extending  from  the  parieto-squamo-mastoid  junction  to  the  tip  of  the  mastoid;  the  upper  two- 
thirds  of  its  length  indicates  the  position  of  the  sigmoid  sinus.  (3)  The  oblique  line  passing 
from  the  asterion  to  upper  limit  of  the  external  auditory  meatus  indicates  the  posterior  two- 
thirds  of  the  sigmoid  sinus  from  its  commencement  to  its  knee. 

giving  warning  when  the  nerve  is  too  closely  approached.  For  its 
avoidance  Macewen  advises  keeping  close  to  the  floor  of  the  middle 
fossa  and  nearer  to  the  posterior  border  of  the  opening,  toward  the 


496  SURGICAL   DIAGNOSIS  AND    TKEATMENT. 

posterior  superior  angle  of  the  suprameatal  triangle.  Should  this  ope- 
ration fail  to  relieve  the  symptoms,  the  abscess  must  be  looked  for  in 
the  temporo-sphenoidal  lobe  by  a  new  opening.  This  opening  should 
be  made  one  and  a  quarter  inches  behind,  and  the  same  distance  above, 
the  external  auditor)'  meatus.  A  quarter-inch  trephine  is  large  enough 
to  begin  with,  the  opening  being  afterward  enlarged,  if  necessary,  by 
the  rongeur  forceps.  The  dura  mater  is  incised  and  a  grooved  director 
passed  into  the  brain-tissue,  as  already  described.  The  instrument 
should  be  made  to  take  a  direction  toward  the  opposite  ala  of  the 
nose — that  is  to  say,  downward,  forward,  and  inward.  Failing  to  find 
pus  in  this  direction,  the  director  is  withdrawn  and  careful  search  made 
in  other  parts  of  the  lobe. 

Thrombosis  of  the  lateral  sinus  is  a  sequel  of  suppurative 
disease  in  the  middle  ear,  and  is  usuall)-  associated  with  pyemia.  The 
symptoms  are  so  similar  to  those  of  cerebral  abscess  that  until  recent 
years  the  two  conditions  were  confounded.  Like  abscess,  thrombosis 
occurs  in  the  course  of  chronic  otitis  media,  and  is  ushered  in  by 
vomiting,  headache,  and  pain  in  the  region  of  the  sinus.  Rigors  and 
rapid  rise  of  temperature  are  common,  there  is  edema  behind  and  over 
the  mastoid,  and  the  cervical  glands  may  be  enlarged.  In  many  cases 
there  are  the  general  symptoms  of  pyemia.  When  pyemic  symptoms 
are  wanting  the  diagnosis  must  rest  upon  two  points — viz.  tenderness 
along  the  course  of  the  lateral  sinu.s — that  is,  from  the  external  audi- 
tory meatus  to  the  external  occipital  protuberance — and  tenderness 
along  the  course  of  the  internal  jugular  vein,  the  vessel  feeling  hard 
and  knotted  to  the  fingers.  Choked  disk  is  usually  present,  and  the 
temperature,  as  a  rule,  runs  high,  instead  of  normal  or  subnormal,  as 
in  cerebral  abscess. 

Treatment . — When  allowed  to  go  unrelieved  by  operation,  the  dis- 
ease is  always  fatal,  while  about  66  per  cent,  of  cases  operated  upon 
have  ended  in  recovery.  The  mastoid  is  opened  in  the  manner  already 
described  and  thoroughly  cleansed.  The  sinus  is  next  exposed,  and 
the  thrombus  or  pus,  as  the  case  may  be,  washed  out.  Hemorrhage  is 
checked  by  packing  the  sinus  with  strips  of  iodoform  gauze.  Finally 
the  internal  jugular  is  exposed  down  to  the  farthest  limit  of  the  throm- 
bus, and  here  the  vessel  is  tied  to  prevent  the  clot  extending  toward 
the  heart.  Too  much  stress  cannot  be  laid  upon  the  importance  of 
properly  treating  otitis  media,  which  is  so  common  a  source  of  abscess 
and  thrombosis. 

IX.  CEREBRAL  TUMORS. 

The  tumors  met  with  in  the  brain  are  the  following :  Glioma  is 
formed  in  the  cerebrum,  seldom  in  the  cerebellum  or  the  spinal  cord. 
Sarcoma  occurs  most  commonly  at  the  base  of  the  brain,  and  in  most 
cases  arises  from  the  dura  mater,  the  periosteum,  or  the  bone  itself  It 
varies  in  size  from  a  walnut  to  the  human  fist,  and  may  be  solitary  or 
multiple. 

Carcinoma  is  usually  secondary  to  the  disease  in  the  breast,  the  lung, 
or  the  pleura,  and  occurs  as  a  soft  tumor  in  the  ventricles,  frequently 
causing  hydrops  ventriculorum.     Tubercular  growths  are  the  most  fre- 


INJURIES  AND  DISEASES   OF  THE  HEAD.  497 

quent  of  all  cerebral  neoplasms.  Their  most  common  seats  are  the 
pons,  the  cerebellum,  and  the  cortex.  Syphilomata  or  gummata 
chiefly  occur  in  the  dura  mater,  and  thence  spread  to  the  brain-sub- 
stance. The  growths,  in  appearance,  closely  resemble  tubercles,  but 
are  readily  distinguished  by  absence  of  the  tubercle  bacilli. 

Symptoms. — Tumors  of  the  brain  produce  no  symptoms  until  they 
are  sufficiently  developed  to  cause  irritation  by  pressure  upon  or  de- 
struction of  the  neighboring  brain-tissue.  Apart  from  pressure,  how- 
ever, it  is  certain  that  tumors,  especially  those  of  an  infective  character, 
are  capable  of  producing  irritation  of  the  adjacent  parts,  which  may  be 
manifested  by  clearly-marked  symptoms.  The  evidences  of  a  cerebral 
tumor  are  of  two  kinds,  general  and  focal. 

General  Symptoms. — Hcadaclic  is  one  of  the  earliest  and  most 
constant  of  all  the  symptoms.  It  begins  as  a  dull,  indefinable  pain 
which  the  patient  cannot  localize.  His  head  aches  all  over,  and  as  the 
disease  advances  the  suffering  may  be  so  intense  as  to  threaten  his 
reason.  The  slightest  movement  or  the  slightest  percussion  of  the 
head  greatly  aggravates  the  pain.  It  is  difficult  to  imagine  a  more 
pitiable  condition  than  that  caused  by  a  cerebral  tumor.  Tormented 
by  day  and  by  night,  the  patient  has  occasional  remissions,  but  never 
freedom  from  pain — pain  that  even  continues  in  sleep,  and  wears  and 
wastes  the  sufferer  till  his  nervous  system  becomes  a  wreck — no  relief 
from  remedies,  no  hope  of  ease  except  through  long-delayed  death. 

Pain,  as  distinguished  from  headache,  is  an  almost  constant  symp- 
tom.    It  is  increased  by  pressure,  but  more  particularly  by  percussion. 

Vomiting  is  generally  present.  It  has  no  connection  with  the  inges- 
tion of  food,  is  unattended  with  nausea,  furred  tongue,  or  constipation. 

Epileptiform  convulsions  may  be  general  or  confined  to  one  side,  and 
in  one  or  other  of  these  forms  they  occur  in  about  50  per  cent,  of  all 
cases.  Consciousness  may  or  may  not  be  lost  during  the  attacks.  The 
value  of  convulsions  as  a  diagnostic  sign  is  thus  summed  up  by  Horsley  : 
"  Of  all  the  initial  symptoms  of  cerebral  tumor,  the  epileptic  convulsion 
is  the  most  important,  not  only  because  it  is  a  clear  indication,  but  also 
because  tumors  causing  the  most  characteristic  forms  of  epilepsy  are 
the  most  easily  removed.  The  convulsions  may  be — i.  General,  and 
so  simulate  idiopathic  epilepsy ;  2.  GeneraHzed,  but  preceded  by  a 
localized  aura ;  3.  Though  generalized,  also  commenced  by  a  local- 
ized muscular  spasm ;  4.  A  typical  Jacksonian  fit,  becoming  in  some 
cases  more  generalized,  and  in  some  followed  by  a  certain  degree  of 
paralysis;  or,  5.  It  may  evince  itself  by  single  spasms,  not  grouped  as 
in  a  complete  fit." 

Some  idea  of  the  location  of  the  tumor  may  be  formed  by  studying 
the  characters  of  the  fit.  "  Lesions  of  the  frontal  lobe  appear  to  pro- 
duce convulsions  of  the  generalized  type,  and,  above  all,  as  Dr. 
Jackson  has  often  pointed  out,  convulsions  in  which  movements  of 
a  half-purposive  character  are  very  prone  to  be  exhibited."  The  first 
disturbance  during  the  fit  is  the  turning  of  the  head  and  eyes  to  the 
opposite  side,  and  this  is  explained  by  the  fact  that  the  cortical  center 
for  this  movement  is  situated  farthest  forward  of  all  the  centers,  and 
the  progress  of  the  disease  is  from  before  backward. 

"  The  parietal  lobe  may  be  assumed  to  be  the  seat  of  tumor  if  the 

32 


498  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

convulsions  arc  of  the  pure  Jacksonian  type,  because  the  parietal  lobe 
contains  a  large  proportion  of  the  most  important  motor-centers. 

"  Tumors  of  the  parieto-occipital  region  will  probably  be  cha- 
racterized by  general  convulsions,  with  ocular  deviation  and  visual 
aura.'. 

"  Tumors  of  the  occipital  lobe  most  commonly  present  generalized 
convulsions,  hemianopsia  from  destruction  of  the  cuneal  region,  and 
are  not  infrequently  accompanied  by  so-called  hysteric  manifestations. 
Hemianopsia,  it  is  to  be  noted,  is  also  a  frequent  and,  in  fact  usual, 
accompaniment  of  tumors  in  the  parieto-occipital  region  when  the 
lesion  burrows  deeply  and  so  affects  the  optic  radiations.  Finally,  in 
the  case  of  tumors  exciting  epilepsy  from  the  occipital  lobe  it  is  to  be 
remembered  that,  owing  to  vertical  pressure  on  the  tentorium,  they 
may  also  give  rise  to  symptoms  resembling  closely  those  of  cerebellar 
growth  ;  for  example,  nystagmus,  tottering,  etc.  Epileptic  convulsions 
from  lesions  of  the  temporal  lobe  have  been  observed  in  cases  of  gross 
organic  disease  (published  by  Dr.  Thomas  Wilson  and  others),  and  are 
preceded  by  a  sensory  aura  of  the  auditory  type,  also  by  the  occur- 
rence of  amnesia ;  and  further,  when  paresis  follows,  it  is  apt  to  be  of 
a  graduated  type  from  the  pressure  on  pyramidal  fibers  and  areas  of 
motor  representation  in  the  cortex.  Those  cases  of  tumor  of  the  inner 
surface  of  the  temporal  lobe  which  have  been  carefully  observed  are 
extremely  interesting,  for  they  have  shown  that  the  epileptic  convulsion 
is  characterized  by  the  occurrence  of  hallucinations  of  smell  and  taste, 
the  special-sense  area  of  representation  of  these  functions  having  orig- 
inally been  demonstrated  by  Dr.  Terrier  to  be  situated  in  this  region. 
It  should  be  noted  that,  whatever  be  the  nature  of  the  fits  in  the  sub- 
sequent progress  of  the  case,  the  initial  attack  is  very  often  a  general- 
ized one.  Moreover,  in  a  certain  number  of  instances  the  attacks  are 
sometimes  localized  and  sometimes  generalized  in  the  same  case.  The 
largest  tumor  I  ever  removed  (the  case  of  a  lady  operated  upon  six 
months  ago,  she  being  still  in  good  health  and  recovering  from  the 
paresis)  was  treated  for  more  than  nine  years  as  one  of  idiopathic 
generalized  epilepsy,  and  that  even  at  a  time  when  the  growth  was 
already  penetrating  the  skull.  A  careful  analysis  and  observation  of 
the  fits  would  have  shown  that  many  of  them  were  characteristically 
unilateral.  The  larger  and  more  deeply  seated  the  growth,  the  more 
generalized  are  the  convulsions.  There  is  frequently  present  in  cere- 
bral tumor  a  general  muscular  weakness,  which  has  often  been  con- 
founded with  simple  neurasthenia,  and  has  sometimes  led  to  a  mistaken 
diagnosis  of  hysteria ;  cases  of  this  kind  have  from  time  to  time  been 
reported." ' 

Vertigo  is  more  characteristic  of  cerebellar  than  of  cerebral  tumor, 
and  a  peculiarity  of  it  is  that  it  continues  while  the  patient  occupies  the 
recumbent  position. 

Iinpairnicnt  of  mental  faculties  constitutes  another  very  important 
general  symptom.  This  is  first  noticed  by  the  patient's  friends,  who 
are  grieved  to  find  that  his  mind  is  becoming  weakened.  His  memory 
begins  to  fail,  he  loses  himself  in  places  that  are  most  familiar  to  him ; 
his  movements  become  slow,  awkward,  and  unsteady,  and  his  face 

^  American  Year-Book  of  Medicine  and  Su7-gery,  1896. 


INJURIES  AND   DISEASES   OF   THE   HEAD.  499 

assumes  a  vacant  and  listless  expression.  Although  he  may  be  highly- 
educated,  the  simplest  arithmetical  problems  are  beyond  him,  and  he 
even  forgets  how  to  read  and  write.  From  this  step  to  complete  in- 
sensibility is  short,  and  he  may  become  so  helpless  as  to  allow  his 
urine  and  feces  to  escape  unheeded. 

Eye-syinptoins  are  often  of  great  value  in  arriving  at  a  diagnosis. 
Choked  disk  is  pretty  constant,  and  may  be  found  in  both  eyes  or 
limited  to  one.  If  the  latter,  it  may  be  fairly  assumed  that  the  tumor 
is  in  the  opposite  hemisphere,  but  no  idea  can  be  formed  of  the  size 
and  position  of  the  growth.  When  choked  disk  and  optic  neuritis  are 
found  coexisting  in  both  eyes,  it  may  be  inferred  that  the  tumor  is  on 
the  side  opposite  to  the  eye  which  has  the  most  swelling.  It  must  not 
be  forgotten  that  simple  anemia  may  cause  choked  disk  just  as  typical 
as  can  be  found  in  cases  of  cerebral  tumor.  Although  neuritis  may  be 
long  continued,  it  must  be  regarded  as  a  transient  symptom.  The 
papillitis  may  have  passed  away,  with  the  exception  of  remnants  in  the 
form  of  spots  of  degeneration  in  the  retina  filling  in  the  center  of  the 
disk  or  white  tissue  along  the  line  of  the  vessels. 

Paralysis  of  a  muscle  or  group  of  muscles  about  the  eye  is  not  of 
special  value  in  the  diagnosis  of  tumor,  except  as  corroborating  other 
symptoms.  It  is  an  evidence  that  the  origin  of  the  nerve  or  the  nerve 
itself  is  suffering  pressure  or  irritation.  Spasm  of  muscle  is  more 
valuable  as  indicating  that  the  cerebral  center  from  which  the  nerve 
arises,  and  not  the  triDik  of  the  nerve,  is  the  seat  of  pressure. 

Hemiplegia  has  been  observed  in  a  number  of  cases,  and,  strange  to 
say,  the  tumor  which  appears  to  produce  it  may  at  the  autopsy  be 
found  in  an  indifferent  area.  We  would  naturally  expect  that  a  right- 
sided  hemiplegia  would  be  associated  with  a  tumor  pressing  on  the 
left  Rolandic  fissure,  but  in  such  cases  the  tumor  has  been  found  in  the 
white  matter  of  the  frontal  lobes  (Hirt). 

Focal  Symptoms. — The  first  of  these  to  demand  attention  is  hemian- 
opsia. If  each  retina  be  divided  into  two  hemispheres  by  a  vertical 
line,  and  it  be  found  that  the  right  half  of  each  is  insensible  to  vision,  it 
will  also  be  found  that  objects  in  the  left  half  of  the  visual  field  are  not 
seen.  If,  on  the  other  hand,  the  left  half  of  each  retina  is  blind,  it  fol- 
lows that  objects  in  the  right  half  of  the  visual  field  are  not  seen.  This 
condition  is  known  as  homonymous  hemianopsia. 

The  great  value  of  this  symptom  is,  that  it  points  to  the  cuneus  as 
the  seat  of  the  lesion,  and  the  tumor,  if  such  be  the  cause  of  compres- 
sion, is  situated  on  the  same  side  as  the  blindness. 

Aphasia. — Is  the  person  right-  or  left-handed  ?  If  left-handed, 
motor  aphasia  is  an  indication  that  the  pressure  is  upon  Broca's  area 
on  the  right  side,  and  if  right-handed,  it  is  upon  the  left  side. 

Sensory  aphasia,  or  word-deafness,  by  which  is  meant  the  loss  of 
memory  of  the  sound  of  a  word,  points  to  the  posterior  half  of  the 
first  left  temporal  convolution  as  the  seat  of  the  lesion. 

Alexia,  or  word-blindness  (the  loss  of  memory  of  words  as  they 
appear  when  written  or  printed),  indicates  that  the  tumor  is  situated  in 
the  left  parietal  lobe  and  at  the  lower  posterior  portion,  especially  the 
angular  and  supramarginal  gyri. 

Agraphia,  or  loss  of  memory  of  the  movements  necessary  to  con- 


500  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

vcy  our  thoufjhts  in  writini:^,  points  to  a  lesion  either  below  Broca's 
area  or  near  the  area  which  controls  movements  of  the  hand. 

Paralysis. — Facial  paralysis  would  be  an  indication  that  the  lower 
third  of  the  opposite  Rolandic  fissure  was  suffering  compression; 
paralysis  of  the  arm  would  point  to  the  middle  third ;  and  paralysis  of 
the  leg,  to  the  upper  third  of  the  fissure  on  the  opposite  side.  The  un- 
certainty of  hemiplegia  as  a  symptom  has  already  been  noted.  When 
focal  symptoms  appear  early  in  the  disease  it  is  an  indication  that  the 
tumor  is  basal,  producing  fatty  degeneration  and  gray  atrophy  of  the 
involved  cranial  nerves  (Hirt). 

A  tumor  in  the  anterior  fossa  of  the  base  will  affect  the  olfactory, 
the  optic,  the  motor  oculi,  and  the  first  branch  of  the  fifth  nerve. 

A  tumor  in  the  middle  fossa  will  affect  the  motor  oculi,  the  pathetic, 
and  the  chiasm  if  situated  above  the  dura  mater,  and  the  ocular  nerves 
and  the  fifth  if  situated  below  the  dura. 

A  tumor  in  the  posterior  fossa  will  affect  the  facial,  the  trigeminus, 
the  auditory,  the  glosso-pharyngcal,  the  vagus,  the  accessorius,  and 
the  abducens  (Hirt).  In  many  cases  it  is  impossible  to  differentiate 
tumors  of  the  posterior  fossa  from  tumors  of  the  cerebellum. 

Diagnosis. — Although  some  cases  present  a  train  of  symptoms 
which,  if  properly  interpreted,  lead  to  a  positive  diagnosis  and  afford 
beautiful  examples  of  inductive  reasoning,  there  are  others  in  which 
the  most  valuable  symptoms  are  in  abeyance  throughout  the  entire 
course  of  the  disease.  Headache  is  a  leading  symptom,  but  there  are 
cases  in  which  it  stands  alone  for  months  or  even  years,  and  without 
the  combination  of  other  general  or  focal  symptoms  it  is  liable  to  be 
regarded  as  obstinate  hemicrania  or  migraine.  Headache  from  causes 
other  than  brain-tumor  is  never  constant.  It  is  relieved  by  ordinary 
remedies,  and  there  are  remissions  during  which  pain  entirely  ceases. 
It  is  not  so  with  cerebral  tumors :  once  in  pain,  always  in  pain — no 
remission  that  brings  complete  relief,  no  restful  sleep,  and  no  improve- 
ment from  the  use  of  drugs. 

In  another  class  of  cases  vomiting  and  vertigo  are  the  only  symp- 
toms. These  two  symptoms  are  common  to  so  many  morbid  condi- 
tions of  the  brain  that  if  unsupported  by  other  evidence  they  do  not 
give  sufficient  data  for  a  diagnosis  of  tumor.  They  are,  however,  suf- 
ficient to  draw  our  attention  to  the  possibility  of  a  tumor,  and  an 
exhaustive  examination  of  the  eye  and  other  focal  symptoms  may 
bring  further  evidence  to  light. 

In  still  another  class  of  cases  convulsions  may  stand  as  the  only 
witness.  The  question  of  epilepsy  must  then  be  settled.  Convulsions 
of  an  epileptic  origin  generally  come  at  intervals  of  considerable  length, 
and  are  more  or  less  relieved  by  bromid  of  potassium  and  other  reme- 
dies. The  convulsions  of  brain-tumors  are  persistent,  and  treatment  is 
of  little  or  no  avail.  The  brain-lesions  which  come  nearest  to  tumors 
are  abscess,  meningitis,  and  thrombosis  of  the  lateral  sinus.  The  onset 
of  tumor-symptoms  is  more  gradual  than  in  any  of  these  :  there  is 
an  absence  of  fever  and  no  change  of  temperature,  except  that  in  the 
later  stages  it  may  be  subnormal,  and  may  be  taken  as  an  indication 
that  the  end  is  not  far  off  In  abscess  there  is  generally  a  cause  which 
leads  up  to  infective  inflammation  and  culminates  in  abscess.    The  pulse 


INJURIES  AND  DISEASES   OF   THE   HEAD.  50I 

is  increased  in  frequency,  and  the  temperature  is  elevated  during  the 
inflammatory  stage  and  changed  to  subnormal  conditions  during  the 
existence  of  the  abscess.  Acute  abscess  of  the  brain  should  give  rise 
to  no  difficulty  in  diagnosis,  but  chronic  abscess  may  in  every  par- 
ticular so  closely  resemble  tumor  as  to  make  a  positive  diagnosis 
impossible.  However,  as  pointed  out  by  Horsley,  this  is  not  of  so 
much  importance  as  might  at  first  appear,  since  the  skull  must  be 
opened  for  the  relief  of  either  condition. 

Meningitis  is  usually  acute  in  its  character  throughout.  Throm- 
bosis of  the  lateral  sinus  has  its  tenderness  along  the  line  from  the 
external  auditory  meatus  to  the  inion,  and  there  is  a  knotty,  tender 
condition  of  the  internal  jugular  vein. 

In  order  to  make  the  examination  complete  and  exhaustive  Weir 
and  Seguin  recommend  that  in  every  suspicious  case  answers  be  ob- 
tained to  the  following  six  questions:  i.  Is  there  a  tumor ?  2.  What 
is  the  location  of  the  tumor  ?  3.  At  what  depth  does  the  tumor  lie — 
that  is,  is  it  cortical  or  subcortical  ?  4.  Is  the  tumor  single  or  mul- 
tiple ?  5.  What  is  the  size  of  the  tumor?  6.  What  is  the  nature  of 
the  tumor  ? 

In  the  present  state  of  our  knowledge  our  answers  must  be  based 
upon  the  following  considerations : 

1.  Is  there  a  tumor?  The  answer  must  be  "Yes"  if  we  find  the 
following  symptoms  or  a  majority  of  them :  {a)  Headache  persistent 
and  not  localized,  with  remissions,  but  never  absence  of  pain,  {li) 
Localized  tenderness  elicited  by  pressure  with  the  thumb.  (<r)  Convul- 
sions, general  or  local,  (c/)  Cerebral  vomiting  and  vertigo,  {e)  Changes 
in  the  mental  condition.  (/)  Paresis  or  paralysis  of  muscles  or  groups 
of  muscles.  (^)  Choked  disk  (not  dependent  upon  anemia),  hemi- 
anopsia, aphasia,  and  other  impairments  of  speech.  Perhaps  the  most 
important  of  all  .signs  of  cerebral  tumors  is  the  fact  that  all  its  mani- 
festations are  steadily  progressive. 

2.  What  is  the  location  of  the  tumor?  The  answer  must  be  deter- 
mined mainly  by  the  focal  symptoms  and  the  character  of  the  con- 
vulsions. 

{a)  The  Frontal  Lobe. — Focal  symptoms  may  be  entirely  wanting  if 
the  tumor  is  in  the  anterior  portion  of  the  lobe,  as  this  is  a  latent  zone. 
In  a  case  reported  by  Raymond  the  symptoms  were  general  weakness 
and  helplessness,  but  no  true  paralysis,  headache,  amaurosis,  and  busy 
psychical  delirium  without  physical  restlessness.  Changes  in  the  dis- 
position of  the  individual,  dementia,  and  mania  are  symptoms  of  the 
greatest  value.  There  are  usually  also  optic  neuritis,  vomiting,  and  the 
characteristic  headache.  Convulsions  can  only  be  of  value  when  the 
disease  has  progressed  toward  the  posterior  portion  of  the  lobe  and 
presses  upon  the  area  which  controls  movements  of  the  head  and  eyes, 
as  already  described. 

{b)  The  Parietal  Lobe. — Here  the  focal  symptoms  are  invaluable,  as 
this  lobe  contains  a  large  area  of  the  principal  motor  centers.  The 
convulsions  are  usually  of  the  pure  Jacksonian  type ;  the  focal  symp- 
toms may  point  to  the  arm,  leg,  or  face  area,  and  the  evidence  is  still 
more  satisfactory  if  the  histor>'  of  the  case  shows  that  the  several  areas 
have  been  encroached  upon  in  their  proper  order. 


502  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

(r)  The  Occipital  Lobe. — Hemianopsia  is  here  a  valuable  symptom, 
as  pointing^  to  the  cuneus.  Frontal  headache,  optic  neuritis,  optic 
spectra,  sometimes  total  blindness  and  widely  dilated  pupils,  are  the 
leading  sj-mptoms.  The  convulsions  are  generalized  and  accompanied 
by  the  so-called  hysteric  manifestations. 

{(i')  The  Pituitary  Body. — According  to  Andriezen,  lesions  of  this 
body  are  manifested  by  the  following  symptoms  :  (i)  Depression  and 
apathy ;  (2)  general  muscular  weakness  ;  (3)  loss  of  fine  co-ordination 
equilibration;  (4)  generalized  twitching  and  spasms  of  the  muscles;  (5) 
subnormal  temperature ;  (6)  wasting  of  the  body-tissues ;  (7)  attacks 
of  dyspnea;  and  (8)  rapid  progress  toward  death.  Woolcombe  reports 
a  case  in  which  all  the  symptoms  except  dyspnea  and  muscular 
twitchings  were  present.' 

{c)  The  Corpora  Qnadrigcniina. — Tumors  in  this  region  are  inter- 
esting on  account  of  the  resemblance  of  their  symptoms  to  those  of 
cerebellar  tumors.  In  one  case,  that  of  a  boy  four  years  of  age,  double 
ptosis  was  the  first  symptom,  after  which  decided  ataxia  of  locomotion 
was  developed,  and  of  the  upper  limbs  two  weeks  later.  He  was 
drowsy,  spoke  slowly,  presented  complete  double  external  ophthalmo- 
plegia, lateral  nystagmus,  and  blindness,  but  no  optic  neuritis  or  cho- 
roiditis. He  died  six  months  after  the  first  symptoms  appeared.  The 
autopsy  showed  the  corpora  quadrigemina  gray  and  gelatinous  in 
appearance,  the  result  of  glio-sarcomatous  infiltration.^ 

3.  At  what  depth  does  the  tumor  lie — that  is,  is  it  cortical  or  subcorti- 
cal? This  question  is  more  easily  asked  than  answered.  In  cortical 
tumor  there  is  usually  an  absence  of  anesthesia,  the  number  of  centers 
pressed  upon  is  not  so  great,  and  the  focal  symptoms  are  more  sharply 
defined.  Local  pressure  by  the  thumb  may  possibly  elicit  tenderness, 
and  there  may  be  a  rise  of  temperature.  We  must  admit  that  our 
knowledge  on  this  point  is  very  limited,  and  when  we  undertake  an 
operation  for  the  removal  of  brain-tumor  we  have  to  take  chances  as 
regards  its  depth. 

4.  Is  the  tumor  single  or  multiple  ?  The  answer  must  rest  upon  the 
precision  of  the  focal  symptoms.  If  only  one  area  suffers  pressure,  the 
tumor  is  single  and  probably  small.  If  several  areas  far  apart  show 
symptoms  of  pressure,  there  are  several  tumors  or  one  very  large 
tumor. 

5.  What  is  the  siae  of  the  tumor?  Here,  again,  the  focal  symptoms 
must  be  our  guide.  The  size  of  the  tumor  is  probably  in  proportion 
to  the  number  and  extent  of  the  areas  pressed  upon. 

6.  What  is  the  nature  of  the  tumor  ?  Statistics  are  of  some  value  in 
answering  this  question.  Before  twenty  years  of  age  tuberculosis  is 
more  frequent  than  any  other  disease.  If  the  patient  has  suffered  from 
cancer  of  the  breast,  lung,  or  pleura,  the  brain-tumor  is  also  probably 
cancerous ;  cases  of  this  kind  are  of  course  beyond  our  help.  Syphi- 
litic gumma  may  be  diagnosticated  if  the  patient  shows  a  history  of 
syphilis  in  other  parts  of  his  body.  As  in  syphilis  elsewhere,  we  can 
always  fall  back  upon  therapeutics  as  an  aid  to  diagnosis,  and,  putting 
the  patient  upon  antisyphilitic  treatment,  watch  the  result.  If,  after 
pushing  the  iodid  for  six  weeks,  and  increasing  the  dose  until  it  reaches 

^  Ann.  of  Med.  Sciences,  1895,  vol  ii.  p.  39,  A.  ^  Op.  cit.,  p.  40,  A. 


INJURIES  AND   DISEASES   OF    THE   HEAD.  5 03 

half  an  ounce  a  day,  there  be  no  improvement,  it  will  then  be  proper  to 
attempt  the  removal  of  the  tumor  by  operation. 

Prognosis. — The  life  of  a  person  suffering  from  a  tumor  of  the  brain 
(except  those  which  are  gummatous  and  yield  to  syphilitic  treatment) 
is  practically  without  hope.  The  symptoms  are  steadily  progressive, 
and  if  left  to  Nature  the  only  result  is  death.  The  duration  of  the  dis- 
ease varies  greatly,  and  the  wiseacre  who  is  in  the  habit  of  setting  dates 
for  his  patients  to  die  is  likely  to  prove  a  false  prophet.  Roughly 
speaking,  the  disease  proves  fatal  at  the  end  of  one  or  two  years,  but 
sudden  death  may  occur  at  any  time,  as  is  peculiarly  the  case  in  brain- 
lesions. 

Treatment. — Except  for  syphilitic  gummata,  no  medicinal  treatment 
affords  the  slightest  hope  of  cure.  Operation  for  the  removal  of  the 
neoplasm  holds  out  the  only  hope  in  the  majority  of  cases,  for,  although 
the  percentage  of  complete  recoveries  is  not  large,  every  case  that  lives 
is  a  life  saved.  Not  more  than  10  to  14  per  cent,  of  all  cases  of  brain- 
tumors  are  so  situated  as  to  warrant  surgical  interference.  In  5  to  7 
per  cent,  the  neoplasm  can  be  removed ;  in  an  equal  number  benefit 
may  be  obtained  by  relieving  pressure.  A  great  deal  of  skill  and  judg- 
ment is  necessary  to  decide  upon  the  propriety  of  operating  in  any 
given  case,  and  the  decision  must  not  be  hastily  arrived  at.  The  ope- 
ration is  practically  the  same  as  that  described  for  abscess  of  the 
brain. 

Tumors  of  the  Cerebellum. — The  early  symptoms  of  tumors  of 
the  cerebellum  are  almost  identical  with  those  attending  growths  in 
the  cerebrum,  except  that  they  come  on  more  rapidly.  Headache  is 
severe,  and,  although  it  may  be  confined  to  the  occipital,  it  is  frequently 
felt  in  the  frontal,  temporal,  or  parietal  region.  Vertigo,  vomiting,  con- 
vulsions, and  optic  neuritis  develop  much  more  rapidly  than  in  cerebral 
tumors.  Later,  there  are  developed  local  symptoms  which  are  very 
characteristic — viz.  cerebellar  ataxia  and  the  staggering  gait.  When 
the  staggering  gait  is  observed,  it  indicates  that  the  middle  lobe  of  the 
cerebellum  is  the  seat  of  a  lesion  or  is  suffering  pressure  from  sur- 
rounding parts.  If  the  symptoms  appear  early  in  the  disease,  we  may 
assume  that  the  tumor  began  in  the  middle  lobe ;  if  it  comes  on  late  in 
the  disease,  the  assumption  is  that  the  tumor  had  its  beginning  in  one 
hemisphere,  and  grew  to  such  an  extent  as  to  exert  pressure  on  the  middle 
lobe.  In  a  case  reported  by  Crafts  the  tumor  began  in  the  hemisphere, 
and  remained  latent  until  it  encroached  upon  the  middle  lobe,  when 
symptoms  suddenly  supervened,  and  death  followed  at  the  end  of  three 
months.  In  a  large  number  of  cases  it  has  been  observed  that  the 
patient  staggers  away  from  the  side  on  which  the  tumor  is  situated. 
In  20  cases  in  which  staggering  to  one  side  was  a  prominent  and  con- 
stant symptom,  16  staggered  away  from  the  side  of  the  lesion  and  4 
toward  the  side  of  the  lesion  (Starr).  According  to  Dr.  Risien  Russell, 
the  deep  reflexes  may  afford  valuable  diagnostic  data.  He  has  proved 
that  in  cerebral  tumor  the  deep  reflexes  are  exaggerated  on  the  opposite 
side,  but  in  cerebellar  on  the  same  side  as  the  tumor.  Other  authori- 
ties place  no  value  on  the  reflexes.  The  cranial  nerve-affections,  such 
as  strabismus,  facial  or  Ungual  paresis,  etc.,  should  be  carefully  studied. 
The  symptoms  appear  on  the  same  side  as  the  tumor.     Paralysis  of 


504  SUKGICA].    DIAGNOSIS  AND    TREATMENT. 

muscles  about  the  eye  is  useful  as  a  diagnostic  point  between  tumor  of 
the  corpora  quadrigemina  and  tumor  of  the  cerebellum. 

If  the  ocular  paralysis  precedes  the  ataxic  symptoms,  the  tumor  is 
in  the  corpora  quadrigemina  ;  if  the  ataxic  symptoms  come  first,  the 
tumor  is  in  the  cerebellum  (Bruns). 

TnatJiicNt. — The  cerebellum  is  not  within  easy  reach,  as  only  one  of 
its  three  surfaces  is  in  contact  with  the  skull,  nor  is  it  possible  to  tell 
whether  a  given  tumor  is  near  that  surface  or  in  a  more  remote  and 
inaccessible  part.  For  these  reasons  operations  for  the  removal  of 
cerebellar  tumors  are  even  less  encouraging  than  operations  on  the 
cerebrum. 

X.  EPILEPSY. 

It  has  long  been  recognized  that  wounds  and  injuries  of  the  head 
are,  in  a  certain  proportion  of  cases,  followed  by  epilepsy.  In  the 
Franco-Prussian  War,  of  8985  individuals  wounded  on  the  head,  46 
were  afterward  afflicted  with  epilepsy,  while  of  77,461  persons  wounded 
in  the  body  or  extremities,  only  17  became  epileptic. 

This  liability  to  epilepsy  is  one  reason  why  scalp  wounds,  fractures, 
and  other  head-injuries  should  receive  the  most  careful  treatment  at 
the  outset.  It  is  much  easier  to  remove  a  depressed  spiculum  of  bone 
shortly  after  the  accident  than  to  cure  an  epilepsy  which,  as  a  result  of 
the  depression,  comes  on  months  and  years  afterward. 

In  examining  a  patient  suffering  from  epilepsy  we  must  keep  before 
our  minds  the  following  varieties  of  the  disease : 

1.  IdiopatJiic  Epilepsy. — This  is  the  ordinary  disease  as  met  with  in 
medical  practice.  It  has  no  assignable  cause,  and  its  nature  has  never 
been  discovered.  Patients  suffering  from  this  form  of  the  disease  are 
suddenly  seized  with  a  fit ;  they  can  give  no  warning,  except  perhaps  a 
faint  cry ;  they  lose  consciousness  immediately,  and  fall  down  in  con- 
vulsions which  are  general,  first  of  a  tonic  and  then  of  a  clonic  cha- 
racter. These  movements  last  for  several  minutes,  and  then  the  patient 
falls  asleep,  to  awake  in  a  worn  and  exhausted  condition. 

2.  Jacksoniaii  Epilepsy. — Dr.  Hughlings  Jackson  as  far  back  as  1864 
recognized  a  class  of  epileptics  in  whom  the  convulsions  began  with  a 
conscious  sensation  in  some  definite  part  of  the  body,  either  one-half 
of  the  face  or  one  of  the  extremities.  The  sensation  or  aura  is  followed 
by  convulsive  movements  of  the  muscles  of  the  part ;  the  patient,  as  a 
rule,  retains  consciousness  throughout,  except  when  the  convulsion 
becomes  general.  Although  Jackson's  observations  were  made  long 
before  the  question  of  cerebral  localization  had  received  much  light,  he 
positively  affirmed  that  the  parts  of  the  brain  affected  in  epilepsy  of 
this  type  were  the  convolutions  on  either  side  of  the  fissure  of  Rolando. 
Cerebral  localization  has  proved  that  he  was  correct.  It  is  not  un- 
common to  find  this  convulsion  beginning  in  the  face,  thence  spreading 
to  the  arm,  and  lastly  to  the  leg,  indicating  that  the  organic  lesion  is 
producing  irritation  in  the  lower,  middle,  and  upper  thirds  of  the  fissure 
of  Rolando  consecutively. 

The  convulsion  in  Jacksonian  epilepsy  begins  in  four  different  ways  : 
id)  The  motor  form,  ]\x'sX  mentioned,  begins  with  disturbance  in  the 
motor  area,  and  the  aura  is  felt  in  the  face,  the  arm,  the  leg,  etc. 


INJURIES  AND  DISEASES   OF  THE  HEAD.  505 

{b)  The  Sc?isojy  Form. — In  this  variety  one  of  the  special  senses  is 
the  seat  of  the  aura.  If  a  warning  of  an  impending  convulsion  comes 
to  the  patient  as  a  sound,  the  affected  area  is  in  the  temporal  region ; 
if  as  a  perversion  of  taste  or  smell,  the  temporo-sphenoidal  region  ; 
and  if  as  an  hallucination  of  vision,  the  occipital  region  is  the  part 
affected. 

ic)  The  Aphasic  Form. — In  one  class  of  cases  the  convulsion  begins 
with  spasm  in  one  side  of  the  face,  immediately  followed  by  loss  of  the 
power  of  speech.  This  may  be  the  one  symptom  noted  in  the  whole 
attack.  In  a  right-handed  person  this  would  point  to  a  lesion  in  the 
third  frontal  convolution  in  the  left  hemisphere,  and  in  left-handed  per- 
sons to  a  lesion  in  the  corresponding  area  in  the  right  side. 

{d^  The  Psychical  Form. — In  this  form  there  is  no  convulsion.  The 
patient  suffers  a  temporary  aberration  of  mind.  He  becomes  maniacal 
or  simply  bewildered  and  stupid,  and  afterward  has  no  recollection  of 
what  occurred  during  the  attack.  In  this  class  of  cases  the  lesion  is  in 
the  frontal  lobes. 

The  interesting  feature  in  regard  to  epilepsy  is  that  a  large  number 
of  cases  result  from  injuries.  A  spiculum  of  bone,  a  dense  cicatrix,  a 
depressed  fracture,  and  a  clot  of  blood  resulting  in  a  cyst  are  causes 
which  are  within  the  surgeon's  power  to  remove,  while  the  ordinary 
type  of  general  epilepsy  is  beyond  surgical  aid. 

Epilepsy  resulting  from  traumatism  is  usually  long  delayed,  the  first 
convulsions  coming  on  weeks,  months,  or  even  years  after  the  injury. 
The  fits  at  first  are  mild  and  less  frequent  than  they  are  at  a  later  stage, 
when  the  disease  is  fully  developed. 

In  examining  a  patient  for  epilepsy  the  history  requires  the  closest 
attention  ;  the  minutest  details  of  the  accident,  notwithstanding  it  may 
have  happened  years  before,  must  be  thoroughly  revived.  To  examine 
the  head  for  scars  and  depressions  the  scalp  must  be  shaved.  The  cha- 
racter of  the  convulsions  must  not  be  received  from  the  patient's  friends, 
as  they  are  usually  unable  to  describe  accurately  what  took  place  during 
a  convulsion,  their  minds  having  been  occupied  in  the  care  of  the  patient. 
When  possible,  the  surgeon  himself  should  observ^e  one  of  these  fits, 
or  at  least  have  the  evidence  of  a  trustworthy  nurse.  Care  should  be 
taken  to  ascertain  the  part  in  which  the  aura  begins,  the  muscles  first 
affected,  and  the  order  in  which  the  several  areas  are  attacked.  Thus 
an  aura  beginning  in  the  leg,  followed  by  twitching  of  the  extremity, 
then  twitching  of  the  arm  of  the  same  side,  and  finally  twitching  of 
the  muscles  of  the  face  and  of  speech,  would  indicate  that  the  irrita- 
tion began  in  the  upper  third  of  the  Rolandic  area,  and  travelled 
downward  to  the  lower  end  and  in  front  of  the  fissure. 

Having  studied  the  character  of  the  fits,  the  muscles  involved,  and 
the  area  of  the  brain  which  is  the  seat  of  the  disturbance,  the  question 
of  operation  is  to  be  considered. 

Be  it  remembered  that  the  number  of  cases  of  epilepsy  suitable  for 
operation  is  comparatively  small.  Starr  carefully  observed  427  con- 
secutive cases,  and  came  to  the  conclusion  that  26  were  "  of  organic 
origin  and  suitable  for  operation,  because  it  was  possible  to  locate  the 
lesion  with  approximate  certainty."  The  following  rules  may  serve  as 
a  cruide  in  the  selection  of  cases : 


506  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

1.  Cases  of  ordinary  general  epilepsy  in  which  the  lesion  cannot  be 
definitely  located  are  not  operable. 

2.  In  traumatic  epilepsy,  when  the  focal  symptoms  point  to  a  definite 
locality  in  the  brain  and  the  scar  or  other  injury  correspond,  the  trephine 
opening  should  be  made  at  the  position  of  the  scar. 

3.  When  the  focal  symptoms  do  not  correspond  with  the  scar,  the 
position  of  the  scar  should  be  disregarded,  and  the  opening  made  at  the 
point  indicated  by  the  focalizing  symptoms,  unless  it  be  found  that  the 
scar  itself  is  very  sensitive,  and  that  simple  pressure  upon  it  is  sufficient 
to  bring  on  a  fit.  In  this  case  the  scar  only  should  be  excised  and  the 
result  watched. 

4.  In  epilepsy  of  a  general  type  following  depressed  fracture,  but  in 
which  localizing  .symptoms  are  absent,  the  trephine  opening  should  be 
made  at  the  seat  of  the  fracture. 

Treatment. — The  operation  of  trephining  for  epilepsy  is  conducted 
in  the  manner  already  described.  On  reaching  the  dura  mater  the 
membrane  should  be  carefully  inspected  and  incised  for  the  purpose  of 
examining  the  brain.  Should  scars  be  found  upon  either  the  dura  or 
the  brain,  the  whole  of  the  scar-tissue  must  be  removed — down  to  the 
white  matter  if  necessary.  When  it  is  necessary  to  remove  a  part  of 
the  dura  mater,  its  place  should  be  supplied  by  a  piece  of  the  pericranium 
of  equal  size,  with  the  view  of  preventing  hernia  cerebri. 


CHAPTER    IX. 
INJURIES,   DISEASES,   AND  DEFORMITIES  OF  THE  SPINE. 

Surgical  Anatomy. — The  spinal  column  is  composed  of  thirty- 
three  vertebrje,  of  which  seven  are  cervical,  twelve  dorsal,  five  lumbar, 
and  nine  are  united  to  form  the  sacrum  and  coccyx.  From  the  posterior 
aspect  of  each  vertebra  is  given  off  a  bony  arch  which  forms  a  canal 
for  the  spinal  cord.  The  bodies  of  the  vertebrae,  resting  upon  one 
another,  must  necessarily  be  strongly  supported  in  order  to  give 
strength  and  security  to  the  trunk.  This  support  is  secured  (i)  by 
ligaments  as  follows  :  the  anterior  common  ligament,  the  posterior 
common  ligament,  and  the  ligamenta  subflava ;  (2)  by  five  layers  of 
muscles ;  (3)  by  articulations  with  the  ribs  in  the  dorsal  region.  The 
normal  curves  of  the  spine  are  produced  by  variations  in  thickness  of 
the  bodies  of  the  vertebrae.  There  are  three  of  these  curves,  all  of 
Avhich  are  antero-posterior.  The  cervical  curve  is  convex  in  front,  the 
dorsal  convex  behind,  and  the  lumbar  convex  in  front.  The  spinal 
cord  in  its  passage  through  the  spinal  canal  is  well  protected  by  its 
membranes,  by  cerebro-spinal  fluid,  and  loose  connective  tissue,  which 
latter  contains  a  plexus  of  veins.  These  structures  lie  in  the  following 
order  from  within  outward :  The  pia  mater  with  its  vascular  network 
closely  embraces  the  cord  itself  Next  comes  the  arachnoid,  between 
which  and    the  pia  mater  is    the  subarachnoid    space  containing    the 


INJURIES,   DISEASES,   AND  DEFORMITIES   OF   THE  SPINE.     507 

cerebro-spinal  fluid.  The  dura  mater  is  the  outermost  membrane  ; 
the  subdural  space  separates  it  from  the  arachnoid. 

The  cord  is  steadied  by  the  spinal  nerves  as  they  pass  through  the 
intervertebral  foramina  by  the  cerebro-spinal  fluid  and  by  the  liga- 
mentum  denticulatum. 

A  practical  point,  which  must  be  borne  in  mind,  is  that  each  nerve 
after  emerging  from  the  spinal  cord  does  not  immediately  pass  out 
through  an  intervertebral  foramen,  but  runs  down  the  cord  for  a  variable 
distance,  and  makes  its  exit  through  a  foramen  lower  down.  Thus  the 
eighth  cervical  nerve  arises  from  the  space  between  the  fifth  and  sixth 
cervical  vertebrae,  and  passes  out  through  the  foramen  below  the  spine 
of  the  seventh  cervical  vertebra. 

Bxamination  of  the  Spine. — The  patient  should  have  all  clothing 
removed  to  the  waist,  and  should  stand  erect,  with  the  heels  together, 
the  arms  hanging  down  by  the  sides,  and  the  eyes  looking  forward. 
Infants  should  be  examined  in  the  sitting  position.  The  following 
questions  can  then  be  answered: 

I.  Is  then-  dcfonuity  ?  The  natural  curves  of  the  spine  may  be 
increased  or  diminished  or  the  whole  spine  may  be  arched  backward  in 
one  great  curve.  This  is  a  sign  of  debility.  It  is  suspicious  of  rickets, 
and  when  in  conjunction  with  it  we  find  swelling  of  the  extremities  of 
the  long  bones  and  the  fontanelles  unclosed,  we  may  call  the  case 
rachitic  spine.  The  spine  may  be  sharply  curved  backward,  as  in 
Pott's  disease,  or  the  vertebrae  may  be  rotated  one  upon  the  others. 
Rotation  is  determined  by  comparing  the  prominence  of  the  angles  of 
the  ribs,  the  lumbar  transverse  processes,  the  height  and  prominence 
of  the  scapula,  and  the  iliac  crests.  The  patient  is  then  viewed  from 
the  front,  and  it  is  noted  whether  one  breast  is  more  prominent  than 
the  other  or  whether  there  is  flattening  of  the  chest  on  one  side.  The 
patient  should  now  be  asked  to  bend  forward  while  he  keeps  the  knees 
straight.  Standing  behind  him,  you  will  be  able  to  determine  the  free- 
dom of  movement  of  the  spine  and  the  presence  or  absence  of  rigidity 
at  any  part.  Rigidity  of  the  muscles,  or  stiffness,  is  one  of  the  earliest 
indications  of  Pott's  disease.  The  tips  of  the  spines  are  next  examined 
by  passing  the  fingers  over  them,  when  any  irregularity  or  abnormal 
prominence  or  lateral  curvature  can  be  noted.  2.  Is  there  tendeniess 
at  any  point?  This  can  be  elicited  by  passing  the  finger  over  the 
spinal  processes.  If  tenderness  is  felt  at  any  spot,  the  skin  should  then 
be  pressed  lightly  or  pinched  up  without  pressing  it  against  the  bone. 
If  pain  is  still  complained  of,  it  is  an  indication  of  hysterical  spine. 
Tenderness  can  also  be  sought  for  by  pressing  downward  upon  the 
spine,  the  hands  of  the  surgeon  being  placed  upon  the  head  or  upon 
the  shoulders  of  the  patient  according  as  the  cervical  or  lower  parts  of 
the  spine  are  being  examined.  This  method,  however,  must  be  used 
with  great  caution,  the  pressure  being  at  first  very  gentle  and  cau- 
tiously increased.  Rough  pressure  may  prove  very  injurious  in  cases 
of  caries  of  the  vertebrae,  and  cannot  be  too  severely  condemned.  3. 
Is  tliere  pain  /  Many  cases  of  spinal  disease  are  attended  with  very 
little  pain.  Sometimes  it  is  felt  in  the  spine  itself,  but  much  more  fre- 
quently the  pain  is  felt  in  front,  at  the  extremities  of  the  nerves,  and 
gives  the  sense  of  constriction.     Such  pains  are  sometimes   spoken  of 


508  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

as  "  girdle  pains."  4.  Is  movcnicnt  restricted?  The  patient  should 
be  asked  to  bend  forward,  backward,  and  from  side  to  side.  He 
should  pick  objects  from  the  floor,  should  walk,  run,  and  jump  from  a 
stool  or  chair.  During  these  exercises  it  must  be  noted  whether  the 
patient  complains  of  pain  or  stiffness  or  tries  to  save  his  spine  by 
causing  the  arms  or  shoulders  to  bear  his  weight. 

Injuries  of  the  Spine. 

Sprains. — Sprains  of  the  back  are  very  common  injuries,  and 
occur  with  all  degrees  of  severity.  Violent  exertion,  as  in  lifting  heavy 
bodies,  may  cause  injuries  of  the  muscles  alone,  resulting  in  a  stiffness 
of  the  back  and  a  local  tenderness  which  soon  pass  off. 

In  more  severe  injuries  the  ligaments  of  the  spine  may  be  over- 
stretched or  torn,  and  in  the  case  of  the  ligamenta  subflava  the  rupture 
may  be  attended  with  hemorrhage,  resulting  in  paralysis.  The  bones 
may  be  injured,  the  vertebrae  separated  from  the  intervertebral  sub- 
stance, and  the  cord  itself  may  suffer. 

Symptoms. — These  will  depend  upon  the  extent  of  the  injur}'.  There 
is  usually  more  or  less  shock,  pain,  tenderness,  and  svvelling  ;  ecchy- 
mosis  is  slow  in  making  its  appearance  on  account  of  the  thickness  of 
the  skin.  In  some  cases  a  considerable  quantity  of  blood  is  poured 
out,  forming  a  hematoma,  which  if  not  absorbed  may  require  incision. 
In  severe  cases  it  may  be  a  difficult  point  to  decide  whether  the  spine  is 
fractured  or  not.  The  degree  of  paralysis  will  have  to  settle  the  ques- 
tion. In  severe  sprains  or  contusions,  as  when  a  man  falls  across  a 
beam  or  iron  bar  and  has  his  body  forcibly  doubled  up,  the  lower  limbs 
may  be  more  or  less  paralyzed,  but  the  paralysis  is  never  so  complete 
as  that  which  results  from  fracture. 

A  rigidity  of  the  muscles  is  usually  a  prominent  symptom,  and  in 
medico-legal  cases  plays  an  important  part,  owing  to  its  resemblance 
to  Pott's  disease.  When  the  injury  is  unilateral  the  rigidity  will  be 
confined  to  the  injured  side — a  condition  which  cannot  be  simulated. 

Treatment. — Shock,  if  present,  must  be  relieved  by  stimulants,  mor- 
phin,  or  hot  applications,  after  which  absolute  rest  constitutes  the 
principal  treatment.  Friction  and  massage  are  very  valuable  in  re- 
ducing swelling  and  promoting  absorption,  and  strapping  the  back 
with  broad  bands  of  adhesive  plaster  extending  around  two-thirds  of 
the  body  will  afford  great  relief 

**  Railway  Spine." — The  peculiar  circumstances  attending  rail- 
way accidents,  and  the  frequency  with  which  such  injuries  are  the 
subject  of  litigation,  give  them  special  interest  to  the  surgeon.  A 
person  whose  back  is  injured  in  a  railway  accident  may  sustain  any 
degree  of  injury  from  simple  strain  or  contusion  of  the  muscles  to 
laceration  of  the  ligaments  or  fracture  of  the  spine,  but  additional 
elements  come  into  the  case  by  reason  of  the  fright  and  shock  which 
attend  the  accident.  The  passenger  may  be  roughly  awakened  from 
sleep  by  the  catastrophe.  The  screams  of  his  fellow-passengers,  the 
sight  of  dead  and  mangled  bodies,  the  horrible  sensation  of  being  held 
down  by  portions  of  the  wreck,  and,  to  crown  all,  the  outbreak  of  fire, 
which  he  feels  will  surely  reach  him  before  he  can  be  extricated,  produce 


INJURIES,   DISEASES,   AND   DEFORMITIES   OF   THE   SPINE.      509 

impressions  on  his  mind  which  last  for  weeks  and  months  and  add  a 
neurotic  element  to  the  traumatism.  Long  after  the  injury  has  had  time 
to  heal  the  patient  complains  of  vague  pains  or  pains  that  exist  only 
in  his  imagination.  There  are  tender  spots,  lameness  and  weakness  of 
the  back,  inability  to  incline  the  body  from  one  side  to  the  other  or 
to  move  the  shoulders.  Numbness  and  tingling  in  the  lower  limbs  are 
frequently  complained  of,  as  also  is  anesthesia  or  hyperesthesia.  The 
skin  is  moist,  or  in  some  cases  bathed  in  profuse  perspiration,  while  the 
kidneys  act  freely,  compelling  the  patient  to  get  up  several  times  in  the 
night.  The  eyesight  is  affected,  according  to  the  patient's  story,  al- 
though no  changes  in  the  retina  or  other  parts  of  the  eye  can  be  found 
to  account  for  these  subjective  symptoms. 

The  mental  condition  is  more  or  less  affected.  The  patient  is  nervous 
and  incapable  of  concentrating  his  attention  upon  his  business  or  any- 
thing that  requires  continuous  volition.  He  becomes  despondent  and 
gloomy,  looking  forward  without  hope  and  filled  with  the  idea  that  ruin 
stares  him  in  the  face. 

These  are  the  cases  that  bring  out  two  types  of  expert  witnesses, 
one  side  swearing  that  the  man  is  seriously  injured  and  permanently 
disabled,  the  other  side  testifying  that  the  symptoms  are  fraudulent  and 
only  assumed  for  the  purpose  of  mulcting  the  railway  company.  The 
examination  of  such  patients  must  be  conducted  with  great  care,  and, 
while  it  is  necessary  to  be  guarded  against  so-called  "  litigation  symp- 
toms," fairness  and  justice  demand  that  all  real  symptoms  should  carry 
due  weight.     The  following  suggestions  may  be  of  value : 

1.  Do  not  rely  upon  a  single  symptom,  but  weigh  all  the  symptoms. 

2.  Study  the  manner  of  the  patient,  and  test  his  truthfulness  or 
studied  attempts  to  exaggerate  his  complaints. 

3.  Exclude  all  pains  the  existence  of  which  cannot  be  confirmed  by 
any  physical  evidence,  and  which  rest  wholly  upon  the  unsupported 
statements  of  the  patient  (Dercum). 

4.  Admit  all  pains  the  signs  of  which  are  evoked  without  any 
previous  warning  or  suggestion  (Dercum). 

5.  Pay  especial  attention  to  every  symptom  which  is  beyond  the 
control  of  the  patient,  as  temperature,  deformity,  persistent  rigidity  of 
muscles,  vomiting,  sweating,  bloody  urine,  etc. 

For  estimating  the  value  of  pain  as  a  symptom  Dercum  recommends 
a  method  of  examination  which  is  often  of  great  value.  The  superficial 
tender  spots  are  tested  by  injecting  at  one  of  the  painful  areas  either 
cocain  or,  as  suggested  by  Keen,  simple  cold  water.  If  the  pain  is 
genuine,  the  injection  relieves  that  particular  spot,  while  the  others 
remain  tender. 

Deep-seated  pain  is  most  likely  to  occur  at  the  position  of  the 
injury,  is  more  slowly  developed,  and  is  not  attended  with  hyper- 
esthesia, while  superficial  pain  is  often  hyperesthetic  and  may  occur  at 
points  remote  from  the  seat  of  the  traumatism.  Pressure  upon  one 
part  of  the  body  while  the  patient's  attention  is  directed  to  another  is 
often  sufficient  to  detect  fraud.  Disease  in  the  vertebrae  or  interverte- 
bral substances  can  be  detected  by  pressure  upon  the  head  or  shoulders 
transmitted  through  the  spine.  Percussion  with  an  ordiiiary  plex- 
imeter  is  useful,  for  through   its  aid  tenderness  in  bone  can  be  elicited 


5IO  SURGICAL    DIAGNOSIS  AXD    TREATMENT. 

by  blows  upon  the  soft  parts  which  are  otherwise  painless.  When 
spasm  of  the  muscles  is  excited  by  percussion  it  is  a  valuable  sign,  as 
no  amount  of  practice  on  the  part  of  the  malingerer  will  enable  him  to 
imitate  it.  h'raudulent  persons  are  sometimes  detected  by  the  use  of  a 
battery,  as  shown  by  Keen,  one  electrode  being  applied  in  the  ordinary 
way,  while  the  cord  of  the  other  is  concealed  in  the  hand  and  discon- 
nected. If  the  patient  complains  of  pain,  we  may  know  he  is  dis- 
honest. 

Treatment. — The  traumatic  lesions  require  treatment  on  general 
principles — viz.  rest,  support  to  the  spine,  etc.  The  neurotic  element  is 
more  difficult  to  manage.  From  the  very  first  the  aim  of  the  surgeon 
should  be  to  prevent  the  patient  from  falling  into  the  condition  of 
hypochondriasis.  If  financial  compensation  is  expected,  it  is  advisable 
to  have  the  matter  settled  as  soon  as  possible,  a  prompt  settlement 
being  better  for  the  patient  than  living  in  suspense,  even  if  there  is  a 
prospect  of  obtaining  a  large  amount.  The  idea  of  permanent  inability 
to  work  should  be  prevented,  and  the  patient  urged  to  resume  his 
employment  as  soon  as  possible. 

Concussion  of  the  spinal  cord  is  a  condition  which  probably 
never  occurs,  owing  to  the  effective  manner  in  which  the  cord  is  pro- 
tected and  steadied  in  the  spinal  canal.  When  injuries  of  the  cord 
arise  to  which  the  term  "  concussion  "  seems  applicable,  the  accident  is 
probably  a  capillary  hemorrhage,  a  laceration  of  the  cord,  or  a  vaso- 
motor disturbance  with  exudation  of  serum. 

The  syviptoms  of  so-called  concussion  are  those  of  shock — viz. 
pallor,  nausea  and  vomiting,  syncope,  cold  perspiration,  etc.  The 
symptoms  which  point  to  the  spine  as  the  cause  of  the  shock  are 
numbness,  tingling  or  even  paralysis  of  the  upper  or  lower  limbs,  and 
constriction  of  the  chest.     The  treatment  is  absolute  rest. 

Compression  of  the  spinal  cord  may  arise  from  three  different 
sources  : 

1.  Dislocation  of  a  vertebra,  or  a  fracture  in  which  a  fragment  is 
driven  in  upon  the  cord.  In  cases  of  this  kind  the  symptoms  come  on 
immediately  after  the  accident. 

2.  Hemorrhage. — The  blood  may  be  poured  out  from  the  vessels 
in  the  substance  of  the  medulla,  from  the  vessels  lying  between  the 
medulla  and  its  membranes,  or  from  the  plexus  of  veins  which  lie 
between  the  dura  mater  and  the  spinal  canal.  Hence  there  are  three 
varieties  of  spinal  hemorrhage : 

{a)  Intra-medullary  {Hemato-myeliei). — This  form  is  recognized  by 
its  sudden  onset  and  by  a  history  of  an  injury  or  of  disease  in  which 
there  are  marked  changes  in  the  blood.  There  are  pain,  rigidity, 
spasms,  and  paralysis.  The  pain  is  referred  to  the  back  and  encircles 
the  body  as  the  so-called  "  girdle  pain."  The  reflexes  connected  with 
the  affected  area  are  diminished  or  entirely  lost.  The  symptoms  are 
bilateral,  are  developed  rapidly,  and  usually  end  fatally.  Among  the 
most  distressing  accompaniments  are  bed-sores,  retention  of  urine,  and 
incontinence  of  feces. 

{b)  Extra-meelnllary  {Hemato-raehis). — In  this  form  of  hemorrhage 
the  pain  is  sudden,  severe,  and  referred  to  the  back.  The  symptoms 
are  pain,  tingling,  and  hyperesthesia  along  the  course  of  the  nerves 


INJURIES,   DISEASES,   AND  DEFORMITIES   OF   THE   SPINE.      51I 

which  have  their  origin  near  the  seat  of  the  extravasation,  and  paraly- 
sis more  or  less  marked,  but  seldom  complete.  Convulsions  are  not 
uncommon,  and  there  is  frequently  retention  of  urine. 

Treatment. — The  first  principle  of  treatment  is  absolute  rest.  In 
the  way  of  drugs  iodid  of  potassium  and  mercury  have  been  relied 
upon.  The  question  of  operating  upon  such  cases  is  receiving  atten- 
tion. If  the  hemorrhage  is  low  down  in  the  spinal  column  and  extra- 
medullary,  an  operation  should  be  considered.  If  also  there  be  rapidly 
advancing  paralysis  extending  upward  to  the  more  vital  centers,  opera- 
tion affords  the  only  hope. 

3.  Meningitis  and  Effusion  of  Lymph  causing-  Compression. — 
This  is  most  frequently  met  with  as  a  complication  of  Pott's  disease.  It 
is  a  pachymeningitis,  and  its  most  distinguishing  characteristic  is  that  the 
symptoms  of  paralysis  appear  from  one  to  eight  weeks  after  the  first 
appearance  of  meningitis. 

Wounds  of  the  Back. — While  wounds  of  the  back  are  commonly 
flesh  wounds,  it  occasionally  happens  that  the  penetrating  instrument 
enters  the  chest,  the  abdomen,  or  the  spinal  cord.  Hence  wounds  in 
this  position  should  be  examined  with  special  care.  The  injuries  to  be 
sought  for  are  the  following:  (i)  If  in  the  cervical  region,  the  vertebral 
artery  may  be  wounded  and  may  result  in  a  false  aneurysm.  To  dis- 
tinguish this  from  a  wound  of  the  carotid  is  often  exceedingly  difficult, 
and  several  cases  are  on  record  in  which  the  carotid  was  tied  by  mis- 
take. The  diagnosis  can  be  settled  by  exposing  the  carotid  sufficiently 
to  ascertain  its  relation  to  the  aneurysm  or  by  passing  the  ligature 
around  it,  noticing  the  effect  of  constriction  before  tying.  The  thyroid 
or  occipital  artery  may  also  be  wounded.  (2)  The  cavity  of  the  pleura 
may  be  penetrated.  This  accident  is  recognized  by  air  passing  in  and 
out  of  the  wound  with  each  respiratory  movement.  (3)  The  wound 
may  penetrate  the  abdominal  cavity,  in  which  case  the  symptoms  will 
be  those  of  wounds  of  the  special  organs  involved. 

(4)  The  spinal  cord  may  be  invoh^ed.  The  danger  of  injur}-  to  the 
cord  is  greatest  when  the  direction  of  the  wound  is  from  below  upward, 
the  instrument  passing  between  the  spinous  processes,  the  laminae,  or 
the  transverse  processes.  This  occurs  most  readily  in  the  cervical 
region,  owing  to  the  more  horizontal  direction  of,  and  the  greater  space 
between,  the  spinous  processes.  The  penetrating  instrument  may 
wound  the  bone,  the  membrane,  or  the  cord  itself  A  wound  of  the 
bones  alone  would  present  no  special  symptom.  A  wound  of  the 
membranes  would  be  recognized  by  the  escape  of  cerebro-spinal  fluid. 
A  wound  of  the  cord  itself  would  produce  paralysis,  depending  in  its 
extent  upon  the  structures  divided.  If  the  entire  thickness  of  the 
cord  is  divided,  complete  paralysis,  both  of  motion  and  sensation,  is 
the  inevitable  result.  If  only  one  side  is  divided,  crossed  paralysis  will 
follow — namely,  paralysis  of  motion  on  the  same  side  as  the  injury, 
and  paralysis  of  sensation  on  the  opposite  side.  Later  symptoms  of 
injury  of  the  cord  are  paralysis  of  the  bladder  leading  to  retention  of 
urine,  paralysis  of  the  bowels  resulting  in  incontinence  of  feces,  and 
trophic  changes  producing  bed-sores. 

Treatinoit. — Hemorrhage  is  not  usually  a  marked  symptom.  When 
a  vessel  of  any  size  is  wounded,  the  external  opening  should  be  enlarged 


512  SURGICAL   DIAGNOSIS  A  AW    TREATMENT. 

and  the  divided  ends  of  the  vessel  secured  by  ligature.  Wounds  of  the 
aorta  and  vena  cava  are  of  course  rapidly  fatal.  The  wound  must  be 
treated  on  general  antiseptic  principles,  and  fragments  of  bone  or  foreign 
body  pressing  upon  the  cord  must  be  removed  ;  the  bladder  and  bowels 
should  receive  close  attention.  The  result  will  depend  upon  the  extent 
of  the  injury  to  the  spinal  cord. 

Fractures  of  the  Spine. — Injuries  of  the  spinal  column,  like 
those  of  the  cranium,  receive  their  importance  from  the  delicate 
nature  of  the  contents  of  the  strong  bony  canal.  Fractures  of  the 
vertebrre  are  serious  injuries,  because  the  risk  of  compression,  lacera- 
tion, or  contusion  of  the  cord  is  great  and  the  results  of  such  injury 
are  far-reaching.  In  the  clinical  picture  of  fracture  of  the  spine  the 
salient  points  are  paralysis  of  motion  and  sensation,  loss  of  control 
of  the  bladder  and  rectum,  bed-sores,  and  a  condition  of  utter  help- 
lessness. 

Causes. — Falls  from  scaffoldings,  bridges,  or  buildings,  the  caving-in 
of  tunnels  or  embankments,  and  the  general  smash-up  attending  rail- 
way accidents  are  the  common  causes  of  fracture  of  the  spine.  A  large 
proportion  of  cases  occur  when  the  body  falls  and  in  striking  the  ground 
assumes  the  position  of  forced  flexion,  the  force  being  sufficient  to  crush 
the  bodies  of  the  vertebrae.  It  is  seldom  that  the  fracture  is  uncom- 
plicated. The  force  which  breaks  or  crushes  the  bones  lacerates  the 
ligaments  and  muscles,  and  produces  hemorrhage  of  the  spinal  cord. 
The  part  of  the  column  above  the  fracture  is  usually  dislocated  forward, 
compressing  the  spinal  cord,  or  a  fragment  of  bone  may  be  driven  into 
the  cord. 

Symptoms. — When  the  fracture  is  compound  the  fragments  may  be 
felt  by  the  disinfected  finger  or  by  a  probe.  A  case  of  fracture  of  the 
vertebrae  comes  under  our  notice  under  circumstances  more  or  less  like 
the  following  :  A  man  falls  from  a  ladder  or  is  caught  by  a  "  cave-in," 
or  is  driving  under  a  low  arch  which  catches  and  doubles  him  up.  He 
lies  still,  is  in  great  pain,  and  cannot  bear  to  be  moved  ;  there  is  more 
or  less  paralysis  of  motion  or  sensation,  or  both.  The  seat  of  the  injury 
is  painful  to  touch,  and  there  may  be  evidence  of  displacement  of  the 
bodies  of  the  vertebrae  or  of  their  spinous  processes.  Later  there  is 
evidence  that  the  bladder  and  rectum  are  paralyzed.  These  symptoms 
are,  in  the  main,  common  to  all  fractures  of  the  spine.  They  vary 
according  to  the  part  of  the  spinal  column  which  is  affected,  and  to 
arrive  at  an  exact  diagnosis  we  must  divide  fractures  of  the  spine  into 
those  occurring  in  the  following  sections  : 

First  Section,  tJie  Three  Loiuer  Liiinhar  Vertebrce. — We  may  set  it 
down  as  a  rule  that  the  higher  the  point  at  which  the  fracture  occurs 
the  more  marked  are  the  symptoms  and  the  more  serious  the  conse- 
quences. Fracture  of  the  three  lower  lumbar  vertebrae  is  below  the 
end  of  the  cord,  which  terminates  at  the  level  of  the  second  lumbar 
vertebra.  The  cauda  equina  is,  however,  in  the  way  of  being  injured, 
but,  as  its  fibers  slip  easily  over  one  another,  it  is  possible  for  them  to 
escape.  In  this  event  the  fracture  may  be  free  from  serious  symptoms. 
It  is  probable  that  many  fractures  in  this  locality  have  been  diagnosed 
as  sprains  of  the  back  and  treated  accordingly,  complete  restoration  of 
function  giving  color  to  the  assumption  that  the  diagnosis  was  correct. 


INJURIES,   DISEASES,   AND  DEFORMITIES   OF   THE  SPINE.     513 

When  the  nerves  are  injured  there  is  more  or  less  paralysis  of  the  parts 
which  they  supply. 

Second  Scctio?i,  between  the  Second  Lnnibar  and  the  Tenth  Dorsal 
Vei'tcbrcB. — From  this  portion  of  the  spine  proceed  the  nerves  which 
form  the  lumbar  and  sacral  plexuses.  The  leading  feature  of  fracture 
in  this  section  is,  consequently,  paralysis  of  the  parts  to  which  these 
nerves  are  distributed.  The  lower  limbs  are  palsied,  the  bladder  loses 
its  power  of  expulsion,  the  bowels  act  involuntarily,  and  bed-sores  are 
inevitable.  The  average  duration  of  life  under  these  circumstances  is 
from  six  months  to  two  years. 

Third  Section,  the  Dorsal  Vcrtebm. — In  addition  to  the  symptoms 
just  enumerated,  fracture  between  the  tenth  and  second  dorsal  verte- 
brae is  attended  with  paralysis  of  the  abdominal  muscles  and  the  lower 
chest  muscles.  There  are  tympanites  and  great  abdominal  distention 
from  collections  of  gas.  Respiration  is  interfered  with,  and  owing  to 
the  difficulty  of  expelling  mucus  from  the  bronchi  and  air-ves;cles, 
hypostatic  congestion  and  pneumonia  are  common  complications  and 
may  prove  to  be  causes  of  death. 

Fonrth  Section,  the  Cer7'ical  and  Cervico-dorsal  Regions. — When  the 
first  or  second  dorsal  vertebra  is  the  seat  of  injury,  only  a  portion  of 
the  brachial  plexus  is  involved ;  consequently,  paralysis  of  the  upper 
extremity  is  incomplete.  If  the  fracture  is  in  the  lower  cervical  region, 
the  whole  plexus  is  involved,  and  paralysis  of  the  arms  is  necessarily 
complete,  both  as  regards  sensation  and  motion.  The  respiration  is 
diaphragmatic ;  breathing  is  interfered  with,  especially  expiration,  and 
the  voice  is  weak  or  wholly  lost.  In  some  of  these  cases  the  tempera- 
ture rises  to  a  remarkable  degree — 108°,  110°,  or  112°  F. ;  in  one  case 
recorded  by  Teale  it  was  122°,  and  yet  the  patient  recovered. 

In  the  upper  cervical  region  the  fifth  and  sixth  vertebrae  are  the 
most  likely  to  be  fractured.  Death  may  be  instantaneous,  owing  to 
paralysis  of  the  nerve-center  of  respiration  in  the  medulla  oblongata  or 
injury  to  the  phrenic  nerve. 

Fifth  Section,  the  Atlas  and  Axis. — Fracture  in  this  section  is  almost 
certainly  fatal,  yet  the  patient  lives,  in  a  majority  of  the  cases,  from  a 
few  hours  to  two  weeks.  Exceptional  cases  are  on  record  in  which 
life  was  prolonged — in  one  case  for  fifteen  months  (Shaw),  and  in  an- 
other case  for  fourteen  years  (Hilton).  The  injury  being  in  close  rela- 
tion with  the  medulla  oblongata,  and  above  the  origin  of  the  phrenic 
nerve,  respiration  is  naturally  most  dangerously  interfered  with. 

There  must,  of  necessity,  be  great  difficulty  in  distinguishing  this 
accident  from  dislocation  of  the  bones,  and  in  some  instances  it  is 
impossible  to  settle  the  question  except  by  a  post-mortem  examination. 
Crepitus  is  the  only  symptom  which  can  be  considered  of  value,  and  it 
is  not  advisable  to  search  too  diligently  for  it.  Stiffness  and  rigidity  of 
the  muscles  of  the  neck,  pain  at  the  seat  of  injury,  and  paralysis  of 
everything  below  the  fracture  are  the  signs  usually  present  and  are 
common  to  both  dislocation  and  fracture. 

Diagnosis  of  the  Exact  Position  of  the  Fracture. — When  there  is  suf- 
ficient displacement  to  produce  a  deformity  of  the  spine,  or  in  the 
exceptional  cases  in  which  crepitus  can  be  detected,  or  in  compound 
fracture  in  which  the  finger  or  probe  can  be  used  to  secure  accurate 
33 


514 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


information,  there  is  no  difficulty  in  localizing  the  seat  of  fracture.  In 
many  cases,  however,  these  evidences  are  wanting,  and  we  have  to 
arri\'e  at  a  diagnosis  of  the  level  of  the  fracture  by  the  three  following 
methods  : 

I .  /)')'  Dctcrviiiniig  the  Extent  of  the  Motor  Paralysis. — In  working 
out  the  data  afforded  by  this  method  the  following  table,  from  Keen's 
article  on  "  Fractures  of  the  Spine,"  in  Dennis's  System  of-  Surgery, 
will  be  found  useful.  The  table  is  founded  on  one  devised  by  M.  Allen 
Starr  and  elaborated  by  Mills  : 


Localization  of  the  Functions  of  the  Segments  of  the  Spinal  Cord. 


Segment. 

Muscles. 

Reflex. 

Sterno-mastoid. 

Hypochottdrmtn    (third 

Trapezius. 

to    fourth     cervical). 

Second   and 
third!  cervical. 

Scaleni  and  neck. 
Diaphragm. 

Sudden       inspiration 
produced  by  sudden 
pressure  beneath  the 
lower  border  of  ribs. 

Diaphragm. 

Papillary  (fourth  cervi- 

Deltoid. 

cal  to  second  dorsal). 

Biceps. 

Dilatation  of  the  pupil 

Fourth  cervi- 

Coraco-brachialis. 

produced  by  irritation 

cal. 

Supinator  longus. 
Rhomboid. 

Supra-    and    infra-spi- 
natus. 

of  neck. 

'  Deltoid. 

Scapular  (fifth  cervical 

Biceps. 

to  first  dorsal).     Irri- 

Coraco-brachialis. 

tation  of  skin  over  the 

Brachialis  anticus. 

scapula  produces  con- 

Supinator longus. 

traction    of    scapular 

Supinator  brevis. 

muscles. 

Fifth  cervical.     - 

Deep  muscle  of  shoul- 

Supinator longus  { fourth 

der-blade. 

to  fifth  cervical).  Tap- 

Rhomboid. 

ping  the  tendon  of  the 

Teres  minor. 

supinator  longus  pro- 

Pectoralis    (clavicular 

duces  flexion  of  fore- 

part). 

arm. 

Serratus  magnus. 

Sixth  cervical.    - 


Seventh  cervi- 
cal. 


Biceps. 

Brachialis  anticus. 
Subscapular. 
Pectoralis    (clavicular 

part). 
Serratus  magnus. 
Triceps. 
Extensors  of  wrist  and 

fingers. 
Pronators. 
'  Triceps  (long  head). 
Extensors     of    wrists 

and  fingers. 
Pronators  of  wrist. 
Flexors  of  wrist. 
Subscapular. 
Pectoralis  (costal  part). 
Serratus  magnus. 
Latissimus  dorsi. 
Teres  major. 


Triceps  (sixth  to  seventh 
cervical).  Tapping 
elbow  -  tendon  pro- 
duces extension  of 
forearm. 

Posterior  wrist  (sixth 
to  eighth  cervical). 
Tapping  tendons 
causes  extension  of 
hand. 

Anterior  ii>rist  (seventh 
to  eighth  cervical). 
Tapping  anterior  ten- 
don causes  flexion  of 
hand. 

Palmar  (seventh  cervi- 
cal to  first  dorsal). 
Stroking  palm  causes 
closure  of  fingers. 


Sensation. 

Back  of  neck  and  of 
head  to  vertex  (oc- 
cipitalis major,  oc- 
cipitalis minor,  au- 
ricularis  magnus, 
superficialis  colli,  and 
supraclavicular). 

Neck. 

Shoulder,  anterior  sur- 
face. 

Outer  arm  (supracla- 
vicular, circumflex, 
musculo-cutaneous,or 
external  cutaneous). 

Back  of  shoulder  and 
arm. 

Outer  side  of  arm  and 
forearm  to  wrist  (su- 
praclavicular, circum- 
flex, musculo-cuta- 
neous  or  external 
cutaneous,  internal 
cutaneous,  radial). 


Outer  side  and  front  of 
forearm. 

Back  of  hand,  radial 
distribution  (chiefly 
musculo-cutaneous  or 
external  cutaneous, 
internal  cutaneous). 


Radial  distribution  in 
the  hand. 

Median  distribution  in 
the  palm,  thumb,  in- 
dex, and  one-half 
middle  finger.  (Mus- 
culo-cutaneous or  ex- 
ternal cutaneous,  in- 
ternal cutaneous, 
radial,  median.) 


INJURIES,  DISEASES,   AND  DEFORMITIES   OF  THE   SPINE.     515 


Segment. 


Eighth  cervi 
cal. 


First  dorsal. 


Second  dorsal. 


Second  to 
twelfth   dorsal. 


First  lumbar. 


Second  lumbar. 


Third  lumbar. 


Fourth  lumbar. 


Fifth  lumbar. 


First  and 
second  sacral. 


Third,  fourth, 
and  fifth  sac- 
ral. 


Fifth  sacral 
and  coccygeal. 


Muscles. 

'  Triceps  (long  head). 

Flexors   of  wrist  and 
fingers. 

Intrinsic     hand  -  mus- 
cles. 
[  Extensors  of  thumb. 

Intrinsic     hand  -  mus- 
I        cles. 

\    Thenar      and      hypo- 
I        thenar  muscles. 


I 


Reflex. 


Muscles  of  back  and 

abdomen. 
Erectores  spinae. 


I 

C  Ilio-psoas. 
Rectus. 

Sartorius. 

Ilio-psoas. 

Sartorius. 

Quadriceps  femoris. 

Quadriceps  femoris. 

Anterior  part  of  bi- 
ceps. 

Inward  rotators  of 
thigh. 

Abductors  of  thigh. 

Abductors  of  thigh. 

Adductors  of  thigh. 

Flexors  of  knee. 

Tibialis  anticus. 

Peroneus  longus. 

Outward  rotators  of 
thigh. 

Flexors  of  knee. 

Flexors  of  ankle. 

Peronei. 

Extensors  of  toes. 

Flexors  of  ankles. 

Extensors  of  ankles. 

Long  flexor  of  toes. 

Intrinsic  foot-muscles. 

Gluteus  maximus. 

Perineal. 

Muscles  of  bladder, 
rectum,  and  exter- 
nal genitals. 

Coccvgeus  muscles. 


Epigastric  (fourth  to 
seventh  dorsal).  Tick- 
ling mammary  region 
causes  retraction  of 
the  epigastrium. 

Abdotninal  (seventh  to 
eleventh  dorsal ) . 

Stroking  side  of  ab- 
domen causes  retrac- 
tion of  belly. 

Cremasteric  (first  to 
third  lumbar).  Strok- 
ing inner  thigh  causes 
retraction  of  testicle. 


Patellar  (third  to  fourth 
lumbar).  Striking 

patellar  tendon  causes 
extension  of  leg. 


Gluteal  (fourth  to  fifth 
lumbar).  Stroking 
buttock  causes  dimp- 
ling in  fold  of  but- 
tock. 

Achilles  tendon  (fifth  to 
first  sacral).  Over- 
extension causes  rapid 
flexion  of  ankle,  called 
ankle-clonus. 

Plantar  (fifth  lumbar  to 
second  sacral).  Tick- 
ling sole  of  foot 
causes  flexion  of  toes 
and  retraction  of  leg. 

Vesical  centers. 

Anal  centers. 


Sensation. 

Ulnar  area  of  hand, 
back,  and  palm,  inner 
border  of  forearm. 
(Internal  cutaneous, 
ulnar.) 

Chiefly  inner  side  of 
forearm  and  arm  to 
near  the  axilla  (chiefly 
internal  cutaneous 
and  nerve  of  Wris- 
berg  or  lesser  internal 
cutaneous). 

Inner  side  of  arm  near 
and  in  axilla  (inter- 
costo-humeral.) 

Skin  of  chest  and  abdo- 
men, in  bands  run- 
ning around  and 
downward,  corre- 
sponding to  spinal 
nerves. 

Upper  gluteal  region 
( intercostals  and  dor- 
sal posterior  nerves). 

Skin  over  groin  and 
front  of  scrotum 
(ilio-hypogastric,  ilio- 
inguinal). 

Outer  side  of  thigh 
(genito-crural,  exter- 
nal cutaneous). 

Front  of  thigh  (middle 
cutaneous,  internal 
cutaneous,  long  saph- 
enous, obturator). 


Inner  side  of  thigh,  leg, 
and  foot  (internal  cu- 
taneous, long  saph- 
enous, obturator). 

Back  and  outer  side  of 
leg;  sole;  dorsum  of 
foot  (external  pop- 
liteal, external  saph- 
enous, musculo-cuta- 
neous,  plantar). 

Back  and  outer  side  of 
leg ;  sole  ;  dorsum  of 
foot  (same  as  fifth 
lumbar). 

Back  of  thigh,  anus, 
perineum,  external 
genitals  (small, sciatic, 
pudic,  inferior,  hem- 
orrhoidal, inferior, 
pudendal). 

Skin  about  the  anus 
and  coccyx  (coccyg- 
eal). 


5i6 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


2.  By  Dcicruiining  the  Extent  of  Cutaneous  Anesthesia. — Chipault, 
in  a  paper  reported  in  the  proceedings  of  the  "  Congres  franqaise  de 
Chirurgie,"  1894,  classifies  these  lesions  as  follows  : 

{a)  Cervical  Type. — Anesthesia  spares  only  the  neck  and  the  deltoid 
regions  before  and  behind.  The  four  limbs  and  the  trunk,  including 
the  diaphragm,  are  paralyzed,  while  the  sterno-mastoid  and  the  supe- 
rior part  of  the  trapezius  are  still  able  to  produce  inspiration.  Death 
follows  by  interference  with  respiration.  ///  tliis  type  tlie  lesion  is 
situated  at  the  upper  limit  of  the  third  cervical  segment  (Fig.  217). 


Fig.  217. — Cervical  type. 


Fig.  218. — Superior  brachial  type. 


{p)  Superior  Brachial  Type. — Besides  the  region  cited  in  the  preced- 
ing type,  anesthesia  spares  the  external  part  of  the  arm  and  the  fore 
arm  as  far  as  the  extremity  of  the  radius.  In  addition  to  those  of  the 
neck  and  diaphragm,  some  of  the  muscles  of  the  upper  extremity  are 
preserved — /.  e.  the  supra-  and  infra-spinati,  the  biceps,  the  brachialis 
anticus,  the  deltoid,  and  the  supinators.  By  action  of  these  preserved 
muscles,  which  are  not  balanced  by  their  antagonists,  the  upper  ex- 
tremities take  a  position  very  characteristic  in  abduction  and  slight 
external  rotation  of  the  arm  with  flexion  and  supination  of  the  forearm. 
The  lesion  is  situated  at  the  middle  part  of  the  sixth  cervical  segment 
(Fig.  218). 

{c)  The  Inferior  Brachial  Type. — The  anesthesia,  which  crosses  the 
trunk  at  a  level  three  or  four  fingers'  breadth  below  the  clavicles,  is 
limited  in  the  upper  extremity  to  a  band  occupying  the  axilla,  the 
internal  surface  of  the  arm  and  forearm,  and  about  half  of  the  hand. 
Not  only  are  the  muscles  enumerated  in  the  preceding  type  preserved, 
but  a  certain  number  of  others — /.  e.  the  supra-  and  infra-scapulars,  the 
pronators  and  extensors  of  the  wrist,  the  triceps,  the  pectorales,  the 
latissimus  dorsi  and  teres  major — in  short,  the  muscles  affected  in  the 
upper  extremity  are  the  flexors  of  the  wrist  and  the  intrinsic  muscles 
of  the  hands.  The  shoulder  and  the  neck  are  capable  of  performing 
all  their  movements,  but  the  wrist,  which  can  place  itself  in  pronation. 


INJURIES,   DISEASES,   AND  DEFORMITIES   OF  THE   SPINE.     517 


remains  in  extension.     Tlic  lesion  is  situated  at  the  middle  part  of  the 
eighth  cervical  segment  (Fig.  219). 


Fig.    219. — Inferior    brachial   type   (after 
Chipault). 


Fig.  220. — Fracture  in  dorsal  region. 


When  the  fracture  is  situated  at  any  point  from  the  first  dorsal  to 
the  last  lumbar  segment,  the  anesthesia  will  be  found  at  a  corre- 
sponding point,  as  seen  in  Figs.  220,  221. 

3.  By  Deter77miiiig  the  Condition  of  the  Reflexes. — When  the  patellar 
tendon  is  quickly  struck  by  the 
ends  of  the  fingers,  the  stimulus  is 
conveyed  by  the  sensitive  nerves 
to  the  posterior  cornu  of  the  cord, 
thence  by  the  anterior  cornu  to  the 
motor  root,  and  finally  to  the  ex- 
tensor muscles  of  the  thigh,  caus- 
ing the  leg  to  jerk  involuntarily. 
This  can  occur  only  when  the  cord 
is  intact.  These  quickly-passing 
contractions  can  be  brought  out  by 
the  skin  as  well  as  the  tendons ; 
hence  we  have  j/^///-reflexes  and 
toidon-re^e-KQs.  The  third  column 
of  the  table  on  page  5  1 5  gives  the 
various  reflexes  and  the  manner  in 
which  they  can  be  produced.  The 
patellar  and  other  reflexes  are  of 
special  value  in  determining  whether 
a  lesion  of  the  cord  is  total  or  par- 
tial. If  the  cord  sustain  an  injury 
which  produces  a  total  transverse  destruction,  there  will  be  total 
motor  paralysis  below  the  level  of  the  injury,  complete  anesthesia,  and 


Fig.  221. — Fracture  in  lumbar  region. 


5l8  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

a  total  abolition  of  the  reflexes.  If  the  lesion  of  the  cord  be  but  par- 
tial, the  paral)'sis  and  anesthesia  will  be  incomplete,  and  the  reflexes 
may  be  only  impaired  or  may  even  remain  normal.  Generally  speak- 
ing, the  cases  in  which  there  is  total  loss  of  motion,  sensation,  and 
the  reflexes  are  not  suitable  for  the  operation  of  laminectomy.  A  few 
cases,  however,  are  recorded  in  which  there  was  total  abolition  of  the 
patellar  and  other  reflexes,  and  yet  recovery  followed  the  operation. 

Trcatincjit. — When  the  patient  is  examined  at  the  scene  of  the  acci- 
dent, there  is  little  difficulty,  as  a  rule,  in  arriving  at  a  diagnosis  of  the 
injury;  the  manner  in  which  he  fell  or  was  struck,  the  intense  localized 
pain  in  the  back  and  the  inability  to  move  the  lower  limbs,  give  almost 
an  assurance  of  fracture,  and  the  case  should  be  treated  with  the  care 
which  that  injury  demands.  In  removing  the  patient  to  his  home  or  to 
a  hospital  a  smooth  stretcher,  a  door,  or  a  shutter  should  be  provided. 
When  the  clothing  is  removed,  a  careful  and  thorough  final  examina- 
tion should  be  made,  so  that  further  disturbance  may  be  avoided.  The 
patient  should,  if  possible,  be  placed  on  a  w^ater-bed,  but,  if  this  cannot 
be  obtained,  a  smooth  hair  mattress  covered  with  waterproof  sheeting 
makes  a  good  substitute.  Reduction  of  the  fracture  can  only  be 
attempted  by  gentle  traction  on  the  lower  limbs,  w^hile  counter-exten- 
sion is  made  from  the  shoulders  by  assistants,  the  surgeon  meanwhile 
bringing  about  coaptation  by  direct  manipulation  of  the  fragments.  In 
some  cases  it  is  necessary  to  keep  up  extension  by  means  of  weights 
and  pulleys,  as  employed  in  fracture  of  the  thigh.  For  keeping  the 
parts  in  apposition  it  has  been  recommended  to  suspend  the  patient 
and  apply  a  plaster-of-Paris  jacket  extending  from  the  axillae  to  the 
trochanters.  I  have  in  two  cases  used  a  much  simpler  device  with 
great  benefit.  It  consists  of  two  straight  splints  three  inches  wide  and 
long  enough  to  reach  from  the  scapulae  to  the  pelvis.  They  are  placed, 
properly  padded,  one  on  each  side  of  the  spinous  processes,  and  united 
at  intefvals  with  strips  of  zinc  or  tin.  If  the  fracture  is  in  the  cervical 
region,  the  head  should  be  steadied  by  sand-bags. 

Throughout  the  case  the  greatest  care  must  be  observed  to  prevent 
bed-sores,  to  keep  the  bladder  emptied,  and  to  ensure  perfect  clean- 
liness. 

The  results  of  treatment  of  fracture  of  the  spine  have  been  so  un- 
satisfactory that  an  attempt  should  be  made  in  suitable  cases  to  cut 
down  upon  the  injured  area  and  remove  all  pressure  from  the  cord.  To 
this  operation  the  name  laminectomy  is  applied.  In  deciding  upon  the 
propriety  of  the  operation  w^e  must  be  guided  by  the  following  con- 
siderations : 

1.  The  condition  of  the  reflexes.  It  is  generally  conceded  that  if 
the  patellar  and  other  reflexes  are  entirely  lost,  the  case  is  not  one  for 
operation.  At  the  same  time  we  must  remember  that  in  a  few  cases 
of  such  a  condition  recovery  has  followed  operation. 

2.  The  higher  the  lesion  the  less  favorable  the  conditions ;  and,  as 
a  rule,  it  may  be  said  that  operations  above  the  seventh  dorsal  verte- 
bra will  rarely  prove  successful.  The  most  favorable  situation  is  below 
the  second  lumbar  vertebra. 

Regarding  operations  in  the  region  of  the  cauda  equina  Chipault 
draws  the  following  conclusions  :  "  {a)  In  case  of  lumbar  or  sacral  frac- 


I.VJUJilES,   DISEASES,   AND   DEFORMITIES    OF   THE   SPINE.      519 

ture  with  permanent  or  irreducible  displacement  of  the  bony  fragments 
we  should  interfere  at  once.  (/?)  In  case  of  fracture  which  is  reduced, 
either  spontaneously  or  by  surgical  manipulations,  wait.  If  the  course 
of  the  case  is  toward  recovery,  wait ;  if  the  case  remains  stationary, 
intervention  is  justified  toward  the  end  of  the  first  month — not  earlier 
— since  functional  restoration  may  not  begin  till  toward  this  period  ;  not 
much  later,  since  incurable  spinal  degeneration  may  be  established." 

3.  The  time  at  which  the  operation  should  be  resorted  to.  Com- 
pression of  the  cord  very  speedily  brings  about  destructive  changes, 
and,  if  the  case  is  one  for  operation  at  all,  the  earlier  it  is  performed  the 
better. 

Operation. — Having  prepared  the  field  of  operation  in  the  usual  way, 
the  patient  is  placed  in  the  Sims  position  ;  an  incision  is  made  in  the 
middle  line  not  less  than  four  inches  in  length,  which  can  afterward 
be  extended  if  required.  The  muscles  are  then  exposed  and  separated 
from  the  arches  upon  one  side.  Horsley  has  shown  that  this  can 
best  be  done  by  clean  cuts  of  the  knife  rather  than  by  blunt  instruments. 
In  this  part  of  the  operation  there  is  usually  hemorrhage.  On  this 
account  the  dissection  should  be  carried  on  as  rapidly  as  possible,  and 
the  cavity  packed  with  sponges  wrung  out  of  water  as  hot  as  can  be 
borne  by  the  hands.  Vessels  of  any  considerable  size  must  of  course 
be  caught  by  forceps  and  afterward  ligated.  Having  packed  one  side, 
the  muscles  on  the  other  side  are  separated  and  packed  in  a  similar 
manner.  The  first  packing  is  now  removed  and  the  periosteum 
reflected.  To  do  this  an  incision  is  made  along  the  angle  formed  by 
the  spinous  processes  and  the  laminae ;  the  edge  of  the  periosteum  is 
grasped  with  a  pair  of  dissecting  forceps  and  separated  by  the  aid  of  a 
curved  periosteal  elevator.  The  opposite  side  is  similarly  treated.  The 
muscles  are  held  apart  by  retractors,  which  must  be  small  and  so 
shaped  as  to  be  out  of  the  operator's  way.  When  the  bone  has  been 
fully  exposed  the  spinous  processes  are  divided  close  to  their  bases  by 
strong  bone-forceps  set  at  an  obtuse  angle.  The  laminae  are  next 
divided  in  the  following  manner :  Begin  with  the  vertebra  at  the  middle 
of  the  incision,  and  by  the  tips  of  the  fingers  find  the  vertebral  spaces 
above  and  below ;  then  apply  the  forceps  as  near  the  transverse  pro- 
cess as  possible,  and  divide  the  lamina  by  a  number  of  short  nips  of  the 
instrument.  Having  removed  the  laminae,  the  dura  mater  comes  into 
view  and  should  be  carefully  examined.  If  there  is  no  pulsation,  we 
may  infer  that  the  subdural  space  is  obliterated  at  that  point,  probably 
by  adhesions  or  by  swelling  of  the  cord.  Increased  tension  is  sug- 
gestive of  a  tumor.  A  yellow  color  would  indicate  the  existence  of 
pus  beneath  the  membrane,  while  a  purple  tinge  would  suggest  extrav- 
asated  blood.  In  either  case  the  membrane  should  be  opened  by 
picking  it  up  with  toothed  forceps  at  the  middle  of  the  incision,  open- 
ing it  with  knife  or  scissors,  and  dividing  it  for  the  required  distance  up 
and  down  upon  a  director  or  with  blunt-pointed  scissors.  The  dura 
mater  is  then  retracted,  and  the  subdural  space  explored  by  the  tip  of 
the  finger  or  by  the  aid  of  a  bent  probe  or  pedicle  needle.  Splinters  of 
bone  or  any  other  cause  of  compression  of  the  cord  should  be  removed. 
When  the  body  of  a  displaced  vertebra  is  producing  pressure,  the  cord 
itself  can  be  held  aside,  as  recommended  by  Chipault,  and  the  projecting 


520  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

portions  cut  off  with  s^ouge,  chisel,  or  curette.  A  tumor  on  the  surface 
of  the  cord  should  be  removed,  but  if  it  infiltrate  the  substance  of  the 
latter,  it  is  best  to  let  it  alone.  Having  completed  the  operation  on  the 
spine,  the  dura  is  closed,  either  by  interrupted  or  continuous  catgut 
stitches,  a  small  rubber  drainage-tube  and  a  few  strands  of  chromicized 
catgut  are  laid  along  the  length  of  the  wound ;  over  this  the  muscles 
are  sutured  by  buried  chromicized  catgut,  and  the  skin  and  fascia  closed 
by  silkworm  gut,  silk,  or  silver  wire. 

Gunshot  Wounds  of  the  Spine. — In  the  diagnosis  of  gunshot 
wounds  of  the  spine  great  difficulty  may  be  experienced  in  determining 
the  location  of  the  missile  and  the  injuries  produced  by  it.  The  bullet 
may  wound  the  bone  alone,  it  may  partially  or  completely  sever  the  cord, 
or  it  may  divide  one  or  more  of  the  large  vessels  near  the  column  and 
cause  death  by  hemorrhage.  Vincent  divides  gunshot  injuries  of  the 
cord  into  three  classes:  i.  The  cord  maybe  compressed  by  extrav- 
asated  blood,  by  fragments  of  bone,  or  by  the  projectile  lying  outside 
the  medulla  or  canal.  2.  The  projectile  in  passing  through  the  spine 
has  injured  the  cord.  3.  The  projectile  is  lodged  in  the  .spinal  canal. 
In  the  examination  the  disinfected  finger  and  probe,  although  useful 
in  certain  cases,  must  not  be  relied  upon.  The  degree  of  paralysis,  the 
extent  of  the  anesthesia,  and  the  state  of  the  reflexes  will  serve  to 
localize  the  injury,  as  already  described  under  Fracture  of  the  Spine. 

When  the  bullet  enters  by  way  of  the  chest  or  abdomen  one  or 
more  of  the  important  organs  of  these  cavities  will  probably  be  wounded, 
and  thus  greatly  increase  the  gravity  of  the  situation. 

Treat j/icjit. — When  the  injury  is  confined  to  the  bone,  the  cord  re- 
maining unharmed,  all  loose  spiculae  of  bone  and  foreign  bodies,  such 
as  clothing,  should  be  removed  and  a  rubber  tube  or  strip  of  iodoform 
gauze  placed  in  the  position  which  can  best  maintain  drainage.  When 
there  is  compression  of  the  cord  the  cause  should  be  removed  by 
an  operation.  The  compressing  agent  will  prove  to  be  a  clot,  a 
fragment  of  bone,  or  the  projectile  itself.  The  most  serious  cases  are 
those  in  which  the  projectile  is  lodged  in  the  spinal  canal.  These 
cases,  if  allowed  to  take  their  course,  are  almost  sure  to  result  in 
myelitis,  meningitis,  cystitis,  and  death,  and,  although  affording  little 
hope,  an  operation  gives  the  only  chance  for  recovery.  Cases  in  which 
the  cord  is  severed  had  better  be  let  alone. 

Dislocation  of  the  Spine. — Although  this  accident  is  generally 
a  complication  of  fracture,  there  are  many  cases  recorded  of  pure  dis- 
location. The  injury  occurs  most  frequently  in  the  cervical  region, 
owing  to  the  smaller  size  of  the  vertebrae  and  their  less  intimate  apposi- 
tion. The  fifth  cervical  seems  to  be  the  most  liable  to  displacement. 
In  the  dorsal  region  the  twelfth  segment  is  the  one  most  frequently 
displaced.  In  the  lumbar  region  the  accident  is  very  rare.  The  dis- 
location is  generally  bilateral,  but  a  number  of  unilateral  luxations  are 
recorded.  The  causes  of  the  injury  are  forced  flexion  or  extension, 
extreme  lateral  motion  or  rotation. 

Symptoms. — The  symptoms  so  closely  resemble  fracture,  in  a  large 
proportion  of  cases,  that  it  is  very  difficult  to  arrive  at  a  diagnosis.  The 
presence  of  deformity  and  the  absence  of  crepitus  cannot  be  relied  upon, 
for  deformity  may  be  present  in  fracture,  and  crepitus  we  cannot  with 


INJURIES,   DISEASES,   AND   DEFORMITIES    OF   THE   SPINE.      $21 

propriety  look  for,  lest  serious  injury  be  done  to  the  cord.  Our  main 
reliance  must  be  placed  upon  the  following  points  :  The  neck  is  rigid 
and  the  head  turned  to  one  side  in  unilateral  luxation  ;  the  spinous  and 
transverse  processes  may  be  felt  to  be  displaced.  If  the  dislocation  is 
in  the  upper  cervical  region,  respiration  is  difficult,  or  it  may  even  be 
suddenly  arrested,  producing  death.  The  finger  should  explore  the 
pharynx  for  displacement  of  the  body  of  a  vertebra.  For  the  rest,  the 
paralytic  symptoms  will  afford  some  evidence.  Dislocation  above  the 
brachial  plexus  causes  paralysis  of  both  upper  and  lower  extremities, 
as  well  as  of  the  trunk.  Motor  is  more  marked  than  sensory  paralysis, 
and  may  range  from  slight  paresis  to  complete  paraplegia.  The  attitude 
assumed  by  the  patient  is  sometimes  very  characteristic,  as  in  a  case 
reported  by  Ayres,  in  which  the  head  was  thrown  back,  the  neck  per- 
fectly rigid,  and  the  larynx  projecting  forward. 

Treatment . — This  dislocation  is  a  serious  injury,  and  the  patient's 
friends  should  be  warned  of  two  dangers.  If  reduction  is  attempted, 
instant  death  may  result,  especially  if  the  displacement  is  in  the  upper 
cervical  region.  On  the  other  hand,  to  allow  the  pressure  of  the  dis- 
placed vertebra  upon  the  cord  to  continue  is  certain  to  result  in 
destructive  changes  and  probably  death.  An  attempt  at  reduction 
should  therefore  be  made.  This  is  effected  by  gentle  and  steady  trac- 
tion upon  the  occiput  and  chin.  If  a  displaced  vertebra  can  be  felt  in 
the  phaiynx.  the  finger  of  the  operator  should  make  firm  pressure  upon 
it  while  steady  traction  is  kept  up.  Should  the  luxation  be  unilateral, 
rotation  of  the  neck  should  accompany  extension. 

Deformities  of  the  Spine. — Deformities  of  the  spine  are  con- 
genital or  acquired.  The  congenital  varieties  embrace  the  fol- 
lowing : 

I.  Spina  Bifida. — This  is  the  most  frequent  of  all  defects  of  the  spine, 
and,  roughly  speaking,  occurs  in  i  of  every  looo  children  born.  Its 
mechanism  is  thus  explained :  In  the  embryo  a  furrow  represents  the 
spinal  canal.  The  sides  of  the  furrow  unite  to  form  the  laminae,  which, 
in  their  turn,  coalesce  at  the  spinous  processes.  If  the  laminae  should  fail 
to  unite  in  the  middle  line,  a  cleft  is  the  result,  through  which  the 
membranes  or  the  cord  itself  projects.  The  tumor  thus  formed  is  nearly 
always  found  in  the  back,  but  rare  cases  are  on  record  in  which  the 
cleft  was  in  the  bodies  of  the  vertebrae  and  the  tumor  formed  in  front 
of  the  spinal  column.  It  is  worthy  of  note  that  in  the  lumbo-sacral 
region  the  medullary  groove  closes  at  a  later  period  than  elsewhere, 
and  this  accounts  for  the  clinical  fact  that  in  this  locality  three-fourths 
of  all  cases  of  spina  bifida  are  found.  Next  in  frequency  is  the  neck ; 
in  exceedingly  rare  cases  the  cleft  occupies  the  entire  length  of  the 
spine.  This  malformation  frequently  exists  in  combination  with  other 
defects,  such  as  club-foot,  squint,  cleft-palate,  hydrocephalus,  and  im- 
perfect mental  development. 

A  form  known  as  spina  bifida  occulta  is  difficult  of  diagnosis  from 
the  fact  that  no  cleft  in  the  spine  can  be  recognized  and  there  is  no 
tumor.  Many  of  these  are  characterized  by  a  growth  of  hair  over 
the  part. 

Varieties. — The  classification  of  the  varieties  of  spina  bifida  is  based 
upon  the  contents  of  the  tumor : 


C22 


Si'KGlCAL   DIAGNOSIS  AND    TREATMENT. 


1.  If  the  membranes  alone  escape  through  the  cleft  and  are  filled 
with  the  cerebro-spinal  fluid,  the  tumor  is  called  a  meningocele. 

2.  If  both  the  cord  and  its  membranes  protrude  through  the  cleft, 
the  tumor  is  called  a  ine)ii)igo-inyelocclc. 

3.  If,  in  addition  to  the  protrusion  of  the  cord  and  membranes  the 
central  canal  of  the  spinal  cord  is  distended  with  fluid,  the  term  syringo- 
myelia is  applied  to  the  tumor. 


Fig.  222. — Spina  bifida  (from  a  photograph  in  the  Cook  County  Hospital,  111.). 

The  diagnosis  of  the  variety  is  important  in  deciding  the  question 
of  treatment. 

Symptoms. — A  congenital  tumor  situated  in  the  lumbo-sacral  re- 
gion over  the  center  of,  and  closely  connected  with,  the  spine  can 
almost  with  certainty  be  pronounced  a  spina  bifida  (Fig.  222).  On 
closer  examination  it  will  be  found  to  have  the  following  characters : 


INJURIES,   DISEASES,   AND  DEFORMITIES   OF   THE   SPINE.     523 

In  shape  it  is  usually  round,  uniformly  smooth,  or  with  a  furrow  run- 
ning down  its  middle  line  and  terminating  in  a  pit-like  depression  above 
and  below.  Sometimes  a  groove  runs  on  each  side  of  the  middle 
furrow  like  the  meridians  of  longitude  on  a  globe,  wide  apart  at  the 
equator,  but  meeting  in  the  pit-like  depression  at  each  pole.  The 
tumor  may  be  of  any  size  up  to  that  of  a  child's  head.  The  color  of 
the  skin  over  the  protrusion  is  usually  red,  but  it  may  be  natural ;  the 
skin  is  thin,  and  in  some  cases  covered  with  a  copious  growth  of  hair. 
Sometimes  the  sac  is  translucent,  permitting  us  to  see,  by  the  aid  of 
transmitted  light,  the  nerve-cords  coursing  through  it.  The  fluid  is 
cerebro-spinal,  and  is  therefore  subject  to  changes  of  tension.  If  it  is 
pressed  upon,  the  impulse  can  be  felt  at  the  anterior  fontanelle ;  when 
the  child  cries  or  coughs  the  tumor  becomes  more  tense,  and  the  same 
is  observed  when  the  sitting  posture  is  assumed.  In  many  cases  the 
cleft  in  the  bone  cannot  be  palpated,  but  this  is  not  essential  to  the 
diagnosis. 

The  diagnosis  of  the  variety  of  spina  bifida  is  not  always  easy. 
Meningocele  is  recognized  by  its  fluctuation  and  by  the  absence  of 
any  nerve-cords  when  examined  by  palpation  or  with  transmitted 
light. 

Meningo-myelocele  is  often  attended  with  atrophy,  and  possibly 
paralysis  of  the  lower  limbs  and  paralysis  of  the  sphincter  muscles. 
Syringo-myelia  may  be  determined  by  the  presence  of  a  deep  dimple, 
which  denotes  the  termination  of  the  spinal  cord  and  its  attachment 
to  the  skin,  and  by  the  presence  of  nerve-cords  seen  by  transmitted 
light. 

Treatment. — In  a  majority  of  cases  the  child  is  so  ill-nourished  and 
defective  in  development  that  death  takes  place  at  an  early  age.  The 
skin  over  the  tumor  may  ulcerate  and  slough,  allowing  the  cerebro- 
spinal fluid  to  escape.  If  infection  takes  place,  spinal  meningitis  is 
almost  sure  to  prove  fatal. 

The  treatment  is  generally  simply  palliative.  A  pad  of  absorbent 
cotton  covered  with  vaselin  or  a  moulded  splint  of  rubber  or  celluloid 
should  be  placed  over  the  tumor  and  kept  in  position  by  a  broad  flan- 
nel belt,  so  as  to  exert  gentle  pressure.  A  layer  of  cotton  saturated 
with  collodion  is  a  good  application  and  has  a  tendency  to  cause 
shrinking  of  the  parts. 

If  at  the  end  of  two  months  the  tumor  is  found  to  be  increasing  in 
size  and  the  general  condition  is  going  on  from  bad  to  worse,  the  ques- 
tion of  a  radical  cure  by  operation  may  be  considered.  Two  operations 
are  recognized  by  surgeons  : 

I.  The  Injection  of  lodin.^ — Morton  of  Glasgow  was  the  first  to  use 
a  fluid  which  has  since  gone  by  his  name.  It  consists  of  iodin  gr.  x, 
iodid  of  potassium  gr.  xxx,  and  glycerin  5J.  The  skin  over  the  tumor 
is  disinfected  in  the  ordinary  way,  and  by  means  of  a  trocar  one  dram 
of  Morton's  fluid  is  injected  at  the  side  of  the  tumor,  the  trocar  passing 
obliquely  through  the  skin  and  sac.  This  gives  a  valve-like  puncture 
which  prevents  escape  of  the  cerebro-spinal  fluid.  As  the  trocar  is 
withdrawn  the  skin  should  be  closely  pressed  around  it  to  prevent 
entrance  of  air  or  escape  of  fluid,  and  the  opening  closed  with  iodo- 
formized  collodion  and  absorbent  cotton.     In   successful  cases  rapid 


524  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

shrinking  of  the  cyst  takes  place  and  the  tumor  is  diminished  in  size. 
Should  no  improvement  follow  the  operation,  a  second  injection  should 
be  made  at  the  end  of  ten  days  or  two  weeks. 

2.  Excision. — Two  varieties  of  spina  bifida  are  amenable  to  opera- 
tion— viz.  meningocele  and  favorable  cases  of  meningo-myelocele ;  the 
third  variety,  s)-ringo-myelia,  is  best  let  alone.  In  any  case  where  the 
tumor  is  very  large,  the  skin  thin,  and  there  is  no  likelihood  of  obtain- 
ing a  sufficient  flap  to  cover  the  parts,  excision  is  not  advisable.  The 
operation  should  not  be  resorted  to  before  the  child  has  reached  the 
age  of  two  months.  On  this  point  Bayer  draws  the  following  con- 
clusions : 

1.  The  operation  for  sacral  and  lumbo-sacral  spina  bifida  should  be 
undertaken  at  once  in  all  those  cases  with  ruptured  sacs  that  do  not 
show  paralysis  and  are  not  complicated  by  other  malformations  except 
club-foot. 

2.  It  is  to  be  done  in  cases  that  show  paralysis  as  soon  as  the  child 
is  well  developed. 

3.  In  cases  in  which  the  sac  is  unruptured  and  covered  by  normal 
skin  the  period  of  infancy  should  not  be  selected  for  operation,  although 
operation  must  not  be  postponed  too  long  for  fear  of  injuries. 

The  Operation. — In  simple  meningocele  make  an  elliptical  incision, 
leaving  sufficient  healthy  skin  on  each  side  to  cover  in  the  parts.  Dis- 
sect out  the  sac  down  to  its  neck  or  base.  If  the  neck  is  .small,  it  may 
be  simply  ligated  and  cut  off;  if  the  neck  is  broad,  the  sac  is  excised 
and  the  cut  edges  sutured  together,  serous  surface  to  serous  surface. 
The  sutures  should  be  close  together,  with  the  view  of  preventing 
escape  of  cerebro-spinal  fluid,  for  if  this  take  place  a  fistula  will  result, 
with  an  ever-present  danger  of  infection  and  spinal  meningitis.  The 
flaps  are  then  brought  together  as  accurately  as  possible,  the  stitches 
being  made  to  alternate  with  those  in  the  sac,  thus  aiding  to  prevent 
escape  of  fluid. 

In  meningo-myelocele,  after  opening  the  sac  the  nerv^es  must  be 
separated  from  the  posterior  part  of  the  sac  to  which  they  are  usually 
attached  and  replaced  within  the  spinal  canal.  The  remainder  of  the 
operation  is  devoted  to  the  formation  of  a  proper  covering  for  the  canal, 
and  can  be  carried  out  in  one  of  two  ways : 

1.  The  muscles  on  each  side  of  the  spine  are  loosened  and  brought 
together  in  the  middle  line  (Bayer).  The  fascia  and  skin  are  similarly 
sutured. 

2.  The  arches  of  the  vertebrae  are  divided  close  to  their  bases  by 
means  of  bone-forceps,  pushed  close  to  the  middle  line,  and  retained  by 
sutures  (DoUinger). 

Choice  of  Methods. — It  is  very  evident  that  the  operation  of  ex- 
cision is  gaining  favor  among  surgeons,  and  will  continue  to  do 
so,  as  better  technique  will  fulfil  two  indications — viz.  first,  to  pre- 
vent escape  of  cerebro-spinal  fluid  and  subsequent  fistula;  and  sec- 
ond, the  securing  of  a  proper  covering  for  the  defective  portion  of  the 
spine. 

Already  statistics  show  a  balance  in  favor  of  the  operation  as  against 
injection  with  iodin.  Morton  collected  65  cases  treated  by  injection, 
with  55  recoveries  and   10  deaths,  and  Powers  has  shown  a  mortality 


nVJURIES,   DISEASES,   AND  DEFORMITIES   OF  THE  SPINE.     525 

of  26.6  per  cent.  Powers  also  collected  34  cases  treated  by  excision, 
from  which  he  deducts  3  in  which  the  cause  of  death  was  indefinite, 
leaving  31  cases  with  24  recoveries — a  mortality  of  22.58  per  cent. 
Robson  reports  20  cases,  of  which  16  recovered — a  mortality  of  20 
per  cent. — and,  according  to  Hildebrand's  statistics,  66  per  cent 
recover  after  injection  and  73.5  per  cent,  recover  after  the  operation  of 
excision. 

2.  Sacro-coccygeal  Tumors. — These  are  congenital  tumors,  and  in 
some  instances  are  varieties  of  spina  bifida.  They  occur  in  girls 
more  frequently  than  in  boys,  the  proportion,  according  to  Malte, 
being  44  to   14. 

In  the  diagnosis  of  these  tumors  the  following  points  must  be  kept 
in  mind.  They  differ  from  spina  bifida  by  lying  in  front  of  the  coccyx, 
while  spina  bifida  lies  behind  the  coccyx  and  continuous  with  the  spinal 
canal.  The  tumor  varies  in  size  from  a  hazelnut  to  a  child's  head ;  it 
is  usually  cystic,  and  is  therefore  elastic  and  fluctuating  in  parts.  The 
coccyx  is  pushed  backward  if  the  tumor  is  large,  and  the  patient  may 
experience  considerable  difficulty  in  sitting  down  ;  the  anus  and  genitals 
may  be  displaced  forward.  The  growth  bears  a  strong  resemblance  to 
a  fatty  tumor,  for  which  it  has  sometimes  been  mistaken.  The  treat- 
ment is  excision,  which  must  be  complete,  and  the  greatest  care  must 
be  taken  to  prevent  injury  to  the  rectum. 

3.  Curvature  of  the  Spine. — The  spine  may  be  abnormally  curved 
in  one  of  three  directions:  i.  Laterally — scoliosis ;  2.  Antero-poste- 
riorly,  with  the  convexity  backward — kyphosis,  or  excurvation  ;  3.  An- 
tero-posteriorly,  with  convexity  forward — lordosis,  or  incurvation. 

Lateral  Curvature. — Girls  in  delicate  health  who  are  growing 
rapidly,  and  who  are  obliged  to  keep  up  such  muscular  action  as 
draws  the  spine  to  one  or  the  other  side,  girls  who  sit  for  long  hours 
at  a  desk  or  piano  with  insufficient  support  to  the  back,  the  poor  girl 
who  carries  around  a  baby  brother  until  she  becomes  lop-sided,  the 
child  with  rickets  or  tuberculosis, — all  these  are  liable  to  lateral  curva- 
ture. Disease  of  the  spinal  cord  when  it  produces  atrophy  of  the 
muscles  on  one  side,  over-use  of  muscles  causing  one-sided  hyper- 
trophy, empyema  resulting  in  contraction  of  one  side  of  the  thorax, 
obliquity  of  the  pelvis,  and  sacro-iliac  disease,  are  also  exciting  causes. 
In  examining  a  case  for  curvature  the  child  should  be  stripped  to  the 
waist ;  she  should  stand  upon  both  feet,  with  head  erect  and  arms 
hanging  by  the  sides.  If  the  spinous  processes  form  a  straight  line  in 
the  middle  of  the  back,  if  the  shoulder-blades  are  at  an  equal  distance 
from  this  line,  if  both  sides  of  the  thorax  are  symmetrical,  and  if  the 
gluteal  fold  is  at  right  angles  with  the  middle  line,  there  is  no  curvature 
of  the  spine.  The  patient  should  be  asked  to  stand  in  this  position  for 
several  minutes.  If  the  back  is  weak,  she  will  be  observed  to  drop  one 
shoulder  as  soon  as  she  becomes  fatigued,  and  the  line  of  the  spinous 
processes  will  curve  to  one  side  or  the  other  (Bradford).  This  is  the 
so-called  flexible  spine.  The  curve  is  readily  rectified  by  voluntary 
effort  on  the  part  of  the  patient.  The  history  of  a  case  of  lateral 
curvature  will  show  that  the  patient  belongs  to  one  of  the  classes 
just  mentioned.  If  a  boy,  the  first  indication  of  deformity  is  that  his 
suspender  is  constantly  slipping  over  his  shoulder ;  if  a  girl,  the  dress- 


526 


SURGICAL    DIAGNOSIS  AND    TREATMENT. 


maker  is  the  first  to  notice  that  one  side  needs  padding  to  ensure  a 
good  fit. 

The  oLithne  of  the  curved  spine  can  usually  be  detected  by  the  eye. 
In  fat  subjects  it  ma)'  be  necessary  to  run  the  finger  with  firm  pressure 
along  the  spinous  processes,  which  leaves  a  red  line,  indicating  their 
position  and  demonstrating  the  presence  of  curvature.  The  most  com- 
mon situation  of  the  curve  is  in  the  upper  dorsal  region  and  with  its 
convexity  to  the  right  (Fig.  223).  In  the  lumbar  region  there  is  a  com- 
pensatory curve  with  its  covexity  to  the 
left,  and  in  marked  cases  there  is  fre- 
quently found  another  compensatory 
curve  in  the  cervical  region,  its  convexity 
being  on  the  opposite  side  from  the 
original  curve. 

Curvature  is  not  the  only  deformity, 
for  the  spine  is  more  or  less  rotated  on  its 
axis,  the  spinous  processes  pointing  to 
the  convexity  and  the  bodies  of  the  ver- 
tebrae to  the  concavity  of  the  curve.  The 
scapula  on  the  affected  side  is  slightly 
prominent,  the  ribs  are  abnormally  sepa- 
rated, their  direction  horizontal,  and  their 
angles  projecting. 

On  the  concave  side  the  obliquity  of 
the  ribs  is  exaggerated,  so  that  in  bad 
cases  they  touch  the  crest  of  the  ilium. 
Bradford  recommends  that  the  four  fol- 
lowing points  should  be  determined:  ist. 
Whether  the  spine  is  flexible;  2d.  Whether 
there  is  any  rotation  ;  3d.  Whether  the  ro- 
tation can  be  corrected  by  any  slight  force ; 
4th.  Whether  any  muscular  weakness  is  present. 

Rotation  may  be  assumed  to  be  present  when  one  shoulder-blade, 
usually  the  right,  is  more  prominent  than  the  other,  and  rotation  may 
also  be  assumed  when  one  hip  is  higher  than  the  other.  The  amount 
of  fixed  rotation  can  be  roughly  determined  by  placing  the  patient  flat 
upon  her  face  on  the  floor  or  upon  a  hard  table.  "  An  ordinary  rule  is 
placed  directly  across  the  back  above  the  middle  of  the  shoulder- 
blades  or  across  the  points  of  the  greatest  projection, 
present,  the  rule  will  not  be  parallel  with  the  plane 
patient  lies  "  (Bradford). 

The  question  as  to  whether  the  deformity  can  be  corrected  by  a 
shght  amount  of  force  is  settled  by  suspending  the  patient  or  by  making 
traction  while  he  is  in  the  recumbent  position.  Muscular  weakness  is 
best  determined  by  a  dynamometer  fastened  to  the  floor,  the  straps  of 
which  pass  over  the  patient's  neck.  In  the  act  of  straightening  the 
body  the  muscular  force  is  recorded  upon  the  instrument. 

In  the  prognosis  of  lateral  curvature  the  rate  of  growth  of  the  child, 
the  height  and  weight  compared  with  tables  of  the  average  of  children 
of  the  same  age,  the  persistence  of  a  faulty  attitude  in  standing  or  sitting, 
and  the  general  health  of  the  patient  should  be  taken  into  account. 


Fig.     223. — Lateral     curvature 
greater  severity  (Bradford). 


If  rotation  be 
on  which  the 


INJURIES,   DISEASES,   AND  DEFORMITIES   OF   THE   SPINE.     527 


If  the  child  is  growing  rapidly  and  is  ill-nourished,  it  may  be  fairly  pre- 
dicted that    the  curvature  will   increase,  and   the  condition   is  more 


Fig.  224. — Normal  back,  a  lack  of  support  from  chair  (Bradford). 

serious  if  there  is  marked  rotation.     A  slight  curvature  in  a  healthy 
child  of  normal  rate  of  growth  need  not  cause  anxiety. 


Fig.  225. — Normal  back  curved  from  sitting  in  FiG.  226. — Normal  back  curved  from  stand- 

a  one-sided  position  (Bradford).  ing  on  one  foot  (Bradford). 

Treatment. — The  practitioner  will  do  well  to  heed  two  warnings  :   ist. 
Do  not  tell  the  friends  of  the  little  patient  that  the  disease  is  of  slight 


528 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


importance,  and  that  under  the  use  of  tonics  the  spine  will  rectify  itself. 
2d.  Do  not  employ  braces,  corsets,  plaster  casts,  or  other  mechanical 
supports  ;  these  are  required  only  in  exceptional  cases  and  where  it  is 
necessary  to  correct  deformit)-.  The  muscles  need  development,  which 
can  be  secured  by  exercise  only.  Mechanical  appliances,  therefore,  by 
keeping  the  muscles  at  rest,  do  harm  instead  of  good.  The  treatment 
must  be  directed  toward  three  objects — first,  to  correct  a  faulty  attitude 
or  carriage  ;  second,  to  increase  the  flexibility  of  the  spine ;  third,  to 
correct  excessive  deformity.  Children  with  any  tendency  toward  lateral 
curvature  should  be  provided  with  suitable  chairs.  Fig.  224  shows  the 
lack  of  support  afforded  by  an  ordinary  chair ;  Fig.  225  shows  how 
the  normal  back  is  curved  from  sitting  in  a  one-sided  position  ;  Fig. 
226  shows  the  effect  upon  the  normal  back  of  standing  upon  one  foot. 
The  bed  used  by  such  patients  should  be  smooth  and  firm,  and  they 
should  be  restricted  to  one  small  pillow.  Before  deciding  upon  the 
necessary  exercises  the  back  should  be  examined  while  the  patient  is 
stripped  to  the  waist.  The  faulty  position  should  be  corrected,  as  far  as 
possible,  by  the  patient's  voluntary  efforts,  aided,  if  necessar>%  by  the 
surgeon's  hands.     She  should  then  be  instructed  to  maintain  the  cor- 


227. — Recumbent  backward  bending  (Bradford). 


rected  position  as  much  as  possible,  and  to  always  return  to  it  after 
every  movement  during  exercises.  The  simplest  and  perhaps  the  most 
useful  movements  are  those  wdiich  cause  a  backward  bend  of  the  body. 
This  can  be  done  by  the  patient's  assuming  the  recumbent  position  and 
repeatedly  raising  the  chest  from  the  table  or  floor  (Fig.  227) ;  or  the 
patient  can  lie  on  a  table  with  the  trunk  projecting  over  the  end  and 
an  assistant  steadying  the  body  at  the  hips  and  knees.  She  should 
then  be  directed  to  flex  and  extend  the  body  at  the  hips  while  resist- 
ance is  made  by  the  hands  of  the  attendant  placed  upon  the  shoulders. 
The  patient  should  be  instructed  to  lie  upon  a  smooth  flat  surface  for 
half  an  hour  each  day,  to  walk  for  a  certain  length  of  time  daily  carry- 
ing a  light  weight  balanced  on  the  head,  and  to  swing  for  a  few  minutes 
by  the  hands  from  a  cross-bar.  Swedish  movements,  massage,  and 
electricity  are  valuable  aids  to  treatment. 

2d,  To  increase  the  flexibility  of  the  spine.  When  the  deformity 
cannot  be  corrected  by  the  voluntary  effort  of  the  patient,  aided  by 
moderate  pressure  of  the  surgeon's  hands,  or  when  it  does  not  disap- 
pear while  the  patient  is  suspended  or  assumes  the  recumbent  position, 
we  must  infer  that  a  certain  amount  of  fixed  rotation  is  present.  It 
then  becomes  necessary  to  use  moderate  force  to  stretch  the  contracted 


INJURIES,   DISEASES,  AND  DEFORMITIES   OF  THE  SPINE.     529 

tissues  and  overcome  the  deformity.  Hoffa  of  Wiirzburg  has  devised 
a  simple  apparatus,  which  is  shown  in  Figs.  228,  229.  The  ordinary- 
suspension  apparatus,  aided  by  belts  of  webbing,  can  be  employed  to 
good  advantage.     In  cases  of  severe  deformity  it  is  sometimes  neces- 


FlG.  228. — Recumbent  correcting  appliance  for  pressure-correction,  made  of  iron  piping. 
The  patient  lies  on  a  stretched  sheeting  hammock,  and  correction-pressure  is  applied  by  screws 
(Bradford). 

sary  to  apply  a  plaster  jacket  while  the  patient  is  in  the  corrected  posi- 
tion. The  plaster  should  be  changed  once  or  twice  in  the  month,  and 
this  treatment  persevered  in  until  the  deformity  is  overcome.     After 


Fig.  229. — Recumbent  correcting  appliance  seen  from  above  (Bradford). 

this  suitable  exercises  and  gymnastics  should  be  employed,  and  the 
case  kept  under  observation  during  the  whole  period  of  growth. 

Posterior  curvature,  excurvation,  or  kyphosis,  may  occur  at  any  age, 
but  is  more  frequent  in  people  of  advanced  life.  The  term  should  be 
restricted  to  cases  of  true  curvature,  and  should  not  embrace  the 
angular  deformity  so  commonly  seen  in  Pott's  disease,  and  which  has 
gone   under  the  mathematically  impossible  term  "  angular  curvature." 

Kyphosis  in  children  may  be  induced  by  permitting  them  to  sit  up 
34 


530 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


at  a  vciy  early  age,  by  nursing  them  in  a  sitting  posture,  or  it  may  be  a 
consequence  of  rickets.  In  adolescents  it  is  produced  by  the  same  con- 
ditions that  cause  scoliosis.  In  adults  it  is  found  in  persons  whose  occu- 
pation compels  them  to  maintain  a  stooping 
posture,  and  especially  if  the  subjects  are 
ill-nourished  and  live  under  bad  hygienic 
conditions.  It  is  common  in  those  subject 
to  asthma,  emphysema,  and  rheumatism, 
and  is  then  due  to  the  position  voluntarily 
assumed  for  the  relief  of  their  sufferings.  It 
is  readily  distinguished  from  the  angularity 
of  Pott's  disease  by  the  presence  of  a  true 
curve,  by  the  absence  of  muscular  rigidity, 
pain,  tenderness,  and  suppuration. 

Treatment. — In  infants  and  adolescents 
the  muscles  must  be  developed  by  judicious 
exercise,  the  correction  of  faulty  positions, 
and  on  the  general  principles  laid  down 
under  scoliosis.  In  old  persons  the  condi- 
tion is  usually  permanent,  but  in  marked 
cases  much  benefit  may  be  gained  by  the 
use  of  a  suitable  spinal  brace. 

Anterior  airvatnre,  inairvation,  or  lordo- 
sis, is  an  antero-posterior  curvature  with  its 
convexity  forward,  and  is  usually  found  in 
the  lumbo-dorsal  region.  It  is  often  con- 
genital. The  most  common  causes  of  this 
condition  are  diseases  of  the  posterior  por- 
tions of  the  bodies  of  the  vertebrae,  ankylosis 
of  the  hip-joints,  and  rickets  (Fig.  230). 

Treatment  must  be  directed  to  the  dis- 
ease that  causes  the  deformity. 

Tuberculosis  of  the  Spine,  Spondy- 
litis, or  Pott's  Disease. — When  the  tu- 
bercle bacillus  finds  lodgement  in  the  spine 
it  selects  the  cancellous  tissue  of  the  bodies 
of  the  vertebrae,  and  produces  there  a  group 
of  changes  similar  to  those  found  in  tuber- 
culosis of  the  hip  or  other  joints.  A  brief  survey  of  these  changes 
will  aid  us  in  understanding  the  symptoms  that  mark  the  course  of 
the  disease. 

The  presence  of  the  bacilli  in  sufficient  numbers  in  tissues  too  weak 
to  resist  them  is  soon  followed  by  inflammation  in  the  bone.  Pain  is 
the  result,  greatly  aggravated  on  movement.  To  guard  against  pain 
the  muscles  of  the  affected  part  become  rigid,  and  this  rigidity  is  one 
of  the  earliest  signs  of  the  disease.  The  patient  by  voluntary  action 
assumes  a  posture  that  gives  the  greatest  steadiness  to  the  spine. 
He  stoops,  and  places  his  hands  upon  his  hips  to  relieve  the  diseased 
area  of  the  weight  of  the  head,  shoulders,  and  all  parts  above ;  if  he 
picks  an  object  from  the  ground,  he  gets  down  to  it  by  bending  the 
knee,  while  the  spine  is  kept  rigid. 


Fig.  230. — Hip-joint  disease 
with  lordosis  (from  a  photograph 
in  the  collection  of  Dr.  Gillette). 


INJURIES,   DISEASES,  AND  DEFORMITIES   OF   THE   SPINE.     53 1 

The  inflammation  in  the  bone  may  possibly  be  arrested  at  this  point, 
and  by  resolution  return  to  a  healthy  condition.  Unfortunately,  this 
rarely  occurs.  The  inflammation  is  a  rarefying  osteitis,  and  destructive 
changes  soon  become  apparent ;  caseation  and  disintegration  of  the 
bodies  of  the  affected  vertebra  take  place,  and  the  bony  substance  is 
replaced  by  granulation-tissue.  The  process  extends  to  the  interverte- 
bral disks,  and  they  also  are  destroyed. 

Even  from  this  point  a  return  to  health  is  possible.  Fibrous  tissue 
may  take  the  place  of  the  caseous  masses,  and  ankylosis  may  result 
with  little  or  no  deformity. 

If  the  disease  progresses  still  farther,  liquefaction  of  the  caseous 
masses  takes  place  and  a  collection  of  tubercular  fluid  (improperly 
called  pus)  is  formed,  which,  following  the  path  of  least  resistance, 
makes  its  way  to  the  surface  as  a  spinal  abscess.  Should  this  abscess 
be  opened  carelessly  or  burst  of  its  own  accord,  infection  by  septic  or 
putrefactive  germs,  or  both,  is  sure  to  take  place,  and  the  dire  conse- 
quences of  suppuration  are  added  to  the  already  serious  condition 
produced  by  the  tubercular  process.  Whether  the  abscess  appears  or 
not,  destructive  changes  in  the  bodies  of  the  vertebrae  and  in  the  inter- 
vertebral disks  go  on  apace.  So  much  loss  of  substance  must  neces- 
sarily alter  the  shape  of  the  spine,  and,  as  the  loss  is  at  the  anterior 
part  of  the  bodies  of  the  vertebrae,  the  healthy  vertebrae  above  and 
below  come  nearer  together,  causing  the  spinous  processes  to  project 
in  angular  prominences,  the  so-called  "  angular  curvature."  So  im- 
portant a  feature  is  this  deformity  that  "  angular  curvature  "  has  long 
been  recognized  as  one  of  the  synonyms  of  Pott's  disease. 

The  position  of  this  angularity  is  generally  the  dorsal  region,  and  it 
is  not  uncommon  to  find  a  compensatory  curve  below  it  in  the  form  of 
lordosis  in  the  lumbar  region.  If  the  disease  occurs  in  the  cervical  or 
lumbar  region,  where  there  is  a  natural  curve,  the  effect  may  be  to 
cause  this  normal  curve  to  disappear,  and  a  straightening  of  the  spine  is 
the  result.  In  diagnosis,  therefore,  a  straightness  of  the  cervical  or 
dorsal  portion  of  the  spine  and  an  obliteration  of  the  normal  curves 
must  be  regarded  as  of  the  same  clinical  value  as  "  angular  curvature." 

Another  symptom  of  spinal  disease  yet  remains  to  be  accounted 
for — /.  e.  paralysis.  The  inflammatory  process  is  not  confined  to  the 
osseous  tissue.  In  many  cases  there  is  inflammation  of  the  dura  mater 
and  of  the  connectiv^e  tissue  between  it  and  the  walls  of  the  canal.  A 
thickening  of  the  tissues  results,  which  by  pressure  upon  the  nerves 
produces  paralysis.  If  the  thickening  is  in  front  and  affects  the  ante- 
rior roots  of  the  nerves,  motor  paralysis  only  is  observed.  If  both 
roots  are  involved,  there  is  paralysis  of  both  sensation  and  motion. 
Paralysis  may  also  be  caused  by  inflammation  of  the  cord  itself  or  by 
the  pressure  of  a  displaced  vertebra  upon  it.  It  is  an  important  clinical 
fact  that  the  liability  to  paralysis  is  greater  the  higher  the  portion 
of  the  spinal  column  that  is  affected,  owing  to  the  larger  size  of  the 
spinal  cord  and  the  smaller  size  of  the  bodies  of  the  vertebrae. 

Symptoins. — In  typical  cases  the  symptoms  of  Pott's  disease  are  so 
characteristic  that  an  error  in  diagnosis  is  scarcely  possible.  There  are 
cases,  however  in  which  the  symptoms  are  far  from  typical,  and  per- 
haps no  disease  assumes  a  greater  variety  of  forms  or  appears  under  so 


532  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

many  different  guises  as  tuberculosis  of  the  spine.  In  the  lumbar 
region  it  may  so  closely  simulate  hip-disease  as  to  deceive  the  most 
careful  observer,  while  in  the  cervical  region  the  evidence  may  point  to 
a  simple  wry-neck  and  nothing  more. 

Pain  is  present  in  nearly  every  case,  and  is  one  of  the  leading  symp- 
toms. It  requires  the  most  careful  study,  as  it  is  sometimes  misleading 
to  both  parents  and  surgeon.  It  is  generally  symmetrical,  and  is  often 
confined  to  the  peripheral  ends  of  the  nerves.  Hence,  instead  of  being 
felt  in  the  back,  it  may  be  felt  in  the  abdomen,  giving  rise  to  the  belief 
that  the  patient  has  stomach-ache  or  some  abdominal  disorder ;  or  it 
may  be  confined  to  the  chest  and  pass  for  intercostal  neuralgia ;  or 
it  may  run  down  the  arms  or  lower  limbs  and  take  the  name  of 
"  growing  pains."  Like  all  pains  connected  with  bone,  it  is  worse 
at  night,  and  may  even  assume  the  character  of  the  "  starting  pains  " 
which  cause  such  suffering  in  hip-disease.  The  location  of  the  pain  will 
vary  with  the  part  of  the  spine  affected.  In  disease  of  the  lumbar 
region  abdominal  pains  are  felt,  and  not  infrequently  there  is  irritability 
of  the  bladder ;  in  the  dorsal  region  the  pain  is  felt  in  the  epigastrium 
or  along  the  course  of  the  intercostal  nerves,  and  the  breathing  is 
sometimes  affected ;  in  the  cervical  region  the  disease  may  cause  pains 
or  numbness  in  the  arms,  difficulty  in  swallowing,  and  a  tickling  cough. 
It  will  thus  appear  that  pain  is  not  a  symptom  of  definite  value.  Its 
uncertainty  should  put  us  on  our  guard  and  lead  us  to  a  close  examina- 
tion of  the  spine  itself  Persistent  pain,  worse  at  night,  in  any  of  the 
positions  just  mentioned  should  create  a  suspicion  of  Pott's  disease. 

The  most  significant  characteristic  of  the  pain  is  its  being  aggra- 
vated by  movement  of  the  spine,  by  jumping,  or  by  twisting  the  body. 
The  patient  should  be  asked  to  jump  from  a  chair  to  the  floor;  pressure 
should  also  be  made  upon  the  shoulders,  so  as  to  gently  crowd  the 
vertebrae  together.  If  these  tests  are  borne  without  pain,  the  spine 
may  be  considered  free  from  disease.  Another  test  consists  in  gently 
lifting  the  patient  by  placing  the  hands  under  the  chin  and  occiput 
while  he  is  in  the  erect  position ;  this  gives  relief  if  the  pain  is  due  to 
Pott's  disease. 

Rigidity  of  the  muscles  is  a  symptom  of  the  greatest  value.  Pain 
may  be  absent,  or,  if  present,  it  may  be  misleading,  while  deformity  does 
not  occur  until  after  much  damage  has  been  done ;  but  rigidity  is  an 
early  and  ever-present  symptom.  It  is  an  effort  to  keep  the  dis- 
eased bones  at  rest  and  prevent  the  movement  that  causes  such 
intense  pain.  The  patient  should  be  stripped  of  all  clothing  and  caused 
to  walk  across  the  floor.  The  gait  is  unnatural  and  the  attitude  is 
peculiar.  Draw  his  attention  to  an  object  behind  him,  and  instead  of 
looking  over  his  shoulder  he  will  turn  his  whole  body.  Ask  him  to 
pick  an  object  from  the  floor,  and  he  bends  the  knee,  while  the  spine  is 
kept  rigid  (Fig.  231).  This  rigidity  gives  rise  to  peculiar  attitudes 
varying  with  the  location  of  the  disease.  When  the  cervical  vertebrae 
are  affected,  the  head  is  sometimes  tilted,  giving  the  appearance  of 
torticollis.  Disease  in  the  upper  dorsal  region  causes  the  patient  to 
assume  the  attitude  seen  in  Fig.  232.  A  very  aggravated  case  is 
shown  in  Fig.  233,  in  which  the  patient  assumes  the  attitude  of  a 
quadruped  in  all  his  locomotion. 


INJURIES,   DISEASES,   AND  DEFORMITIES   OF   THE   SPINE.     5.33 


Deformity. — The  mechanism  of  the  so-called  "  angular  curvature  " 
has  been  already  described.  It  should  be  carefully  sought  for,  as  it  is 
the  earliest  symptom  of  destructive  change,  just  as  shortening  of  the 
limb  is  evidence  of  the  destructive  process  in  disease  of  the  hip-joint. 
It  is  advisable  to  keep  an  accurate  record  of  the  amount  of  deformity, 
and  this  can  best  be  done  by  photographs.  They  do  not  give  an  idea 
of  the  amount  of  rotation  in  cases  of 
lateral  curvature,  but  this  can  be  ob- 
tained if  the  patient  stoops  forward 
and  a  photograph  be  taken  of  the 
bent  back,  or  if  a  mirror  be  placed 
directly  on  the  patient's  head  at  such 
an  angle  as  to  reflect  the  contour  of 
the  back  below ;  if  the  reflection  be 
photographed  the  rotation  will  be  re- 
corded (Bradford). 

Abscess. — Many  cases  of  Pott's  dis- 
ease run  their  course  without  suppu- 
ration, or  without  the  formation  of 
liquid  collections  improperly  called 
"  tubercular   abscesses."     Early    and 


Fig.  231. — Manner  of  picking  up  an 
object  in  Pott's  disease  (Agnew). 


Fig.  232. — Disease  in  upper  dorsal  region 
(from  a  photograph  in  the  collection  of  Dr. 
Gillette). 


efficient  treatment  has  much  to  do  in  the  prevention  of  these  disagree- 
able complications,  though  abscesses  may  form  in  spite  of  the  most 
careful  treatment.  Beginning  as  they  do  in  the  anterior  portion  of  the 
vertebrae  and  in  close  proximity  to  the  important  organs  contained  in 
the  thoracic  and  abdominal  cavities — xiz.  the  esophagus,  the  lungs,  the 


534 


SURGICAL    DIAGNOSIS  AND    TREATMENT. 


large  vessels,  and  the  contents  of  the  peritoneum — it  is  remarkable  that 
spinal  abscesses  are  not  more  frecjuently  followed  by  fatal  results. 
They  afford  examples  of  the  manner  in  which  pus  can  travel  far  from 
its  point  of  origin,  seeking  an  outlet  to  the  surface  in  the  direction  of 
least  resistance. 

When  an  abscess  takes  its  origin  from  the  bodies  of  the  cervical  verte- 
brae it  may  point  to  one  of  the  following  directions :  {a)  Retro-pharyn- 
geal,  the  fluctuation  being  felt  to  one  side  of  the  middle  line  ;  (/;)  The  fluid 
may  burrow  outward  and  point  behind  the  angle  of  the  jaw;  {c)  It  may 


Fig.  233. — Quadruped  locomotion. 


follow  the  course  of  the  esophagus  and  enter  the  posterior  mediastinum  ; 
(^)  It  may  burrow  between  the  longus  colli  and  scaleni  muscles,  and 
point  in  the  neck  at  one  or  other  side  of  the  sterno-mastoid  muscle. 
When  the  dorsal  vertebrae  are  affected,  which  happens  in  the  majority 
of  cases,  the  first  collection  of  fluid  is  in  the  posterior  mediastinum. 
From  this  position  it  may  travel  in  one  of  three  routes  :  {a)  Passing 
between  the  transverse  processes,  it  may  appear  in  the  back — the  so- 
called  dorsal  abscess,  (b)  It  may  burrow  downward  to  the  diaphragm, 
pass  under  the  ligamentum  arcuatum  externum,  and  appear  in  the  ilio- 
costal space  and  become  a  lumbar  abscess  (Fig.  234).  {c)  It  may  pass 
beneath  the  ligamentum  arcuatum  internum  and  between  the  two  origins 
of  the  psoas  muscle,  and  become  a  psoas  abscess.     Its  place  of  point- 


INJURIES,   DISEASES,   AND  DEFORMITIES   OF  THE  SPINE.     535 


ing  is  generally  in  the  groin  below  Poupart's  ligament  and  the  outer 
side  of  the  femoral  vessels.  In  some  cases  it  points  above  Poupart's 
ligament,  and  by  gravitation  it  may  burrow  down  the  thigh  or  even 
below  the  knee. 

Disease  in  the  lumbar  vertebrae  produces  an  iliac  abscess  which 
usually  points  in  the  abdominal  wall  a  little  above  Poupart's  ligament. 
We  cannot  place  much  reliance  upon  the  position  in  which  an  abscess 


Fig.  234. — Lumbar  abscess  (Hoffa). 


Fig.  235. — Severe  grade  of  psoas  contrac- 
tion (from  a  photograph  in  the  collection  of  Dr. 
Gillette). 


points,  for  pus,  with  ever-increasing  pressure,  constantly  burrows  in 
the  direction  of  least  resistance. 

It  is  very  important  to  make  a  diagnosis  of  abscess  before  pointing 
takes  place.  The  formation  of  an  abscess  may  be  suspected  when 
there  is  a  sudden  increase  of  pain,  loss  of  appetite  and  flesh,  and 
general  constitutional  disturbance  in  a  patient  who  had  previously  been 
doing  well.  As  the  psoas  abscess  is  the  most  common  form,  contrac- 
tion of  the  psoas  muscle  is  an  early  symptom  and  a  valuable  diagnostic 
point.  In  some  cases  the  contraction  is  marked  and  causes  great 
deformity  (Fig.  235).  The  manner  of  estimating  mild  forms  of  con- 
traction is  shown  in  Fig.  236.     Psoas  abscess  must  not  be  mistaken  for 


536      .  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

hernia.     When  an  -abscess  appears  suddenly,  is  egg-shaped,  and  free 
from  tenderness  and  heat,  as  it  frequently  is,  its  resemblance  to  hernia 


Fig.  236. — Method  of  e.xamining  for  psoas  contraction  in  Pott's  disease  (Hoffa). 

may  mislead  the  unwary.  Its  position  outside  the  femoral  vessels,  cor- 
roborated by  other  signs  of  Pott's  disease,  should  leav^e  no  room  for 
doubt. 

Paralysis. — This  symptom,  as  already  described,  is  due  to  a  pachy- 
meningitis or  to  a  transverse  myelitis.  Paralysis  of  motion  is  usually 
the  first  to  appear,  varying  from  mere  muscular  weakness  to  com- 
plete paresis.  The  reflexes  are  exaggerated,  except  when  the  lumbar 
vertebrae  are  affected,  and  muscular  spasms  frequently  occur.  If  the 
posterior  roots  suffer  pressure,  there  is  paralysis  of  sensation.  Paralysis 
is  greatly  influenced  by  treatment.  On  this  point  Bradford  and  Lovett 
say :  "  It  occurs  without  regard  to  the  amount  or  character  of  the 
deformity,  and  is  often  preceded  by  much  pain  ;  on  the  average  it  lasts 
a  little  less  than  a  year.  Its  prognosis  is  extremely  favorable  in  mild 
cases,  or  in  severe  ones  if  they  can  be  treated  early.  Recovery,  when 
it  occurs,  is  generally  complete,  no  trace  of  the  disability  of  the  limbs 
being  left.  Incomplete  recovery  is  uncommon,  but  incomplete  paralysis 
often  is  present.  In  fact,  the  early  commencement  of  efficient  treatment 
will  often  seem  to  render  abortive  an  attack  of  paraplegia,  and  change 
what  threatened  to  be  a  complete  loss  of  power  to  a  comparatively 
trifling  disability  which  is  merely  enough  to  prevent  walking  for  a  few 
weeks  or  months." 

Differential  Diagnosis. — A  typical  case  of  Pott's  disease  cannot  be 
mistaken  for  anything  else.  There  are  cases  in  which  pain  is  for  a  long 
time  the  only  symptom,  and  these  are  fruitful  sources  of  error.  The 
surgeon,  misled  by  the  position  of  the  pain,  gives  his  attention  to  intes- 
tinal disorders,  gall-stones,  intercostal  neuralgia,  or  rheumatism,  and 
never  thinks  of  examining  the  spine  for  rigidity  or  deformity. 

Sprains  of  the  spinal  column  may  simulate  Pott's  disease  by  causing 
the  patient  to  assume  an  attitude  resembling  the  latter.  There  may 
even  be  rigidity  of  the  muscles,  and  the  patient  in  attempting  to  walk 
may  place  his  hands  upon  his  thighs  to  support  the  weight  of  the  trunk. 

Sprains  seldom  occur  in  childhood.  The  suddenness  of  the  symp- 
toms, their  evident  connection  with  a  traumatism,  and  the  speedy 
recovery  under  appropriate  treatment  settle  the  question  of  sprain. 


INJURIES,    DISEASES,   AND   DEFORMITIES   OF   THE   SPINE.      537 


Hysterical  or  JiypcrcstJictic  spine  occurs  in  young  growing  girls  and 
in  neurotic  persons.     The  spine  is  tender  in  spots,  and  there  may  be 
intense  pain,  but  the  attitude  and 
gait  of  Pott's  disease,  the  angu- 
larity, and  to  a  certain  extent  the 
muscular  rigidity,  are  absent. 

Wry-neck  is  one  of  the  symp- 
toms of  disease  of  the  cervical 
vertebrae.  Simple  muscular  wry- 
neck is  distinguished  by  the 
rigidity  of  certain  muscles  and 
the  absence  of  pain  attending 
movements  of  all  other  muscles. 

Lateral  curvature,  rickets, 
aneurysm,  rheumatism,  and 
many  other  disorders  may  sim- 
ulate Pott's  disease.  If,  however, 
the  two  characteristic  symptoms, 
muscular  rigidity  and  deformity, 
be  carefully  studied,  it  is  hardly 
possible  to  make  a  mistake. 
Fig.  237  illustrates  a  case  of 
rachitic  curvature.  Note  the 
true  curve  instead  of  the  "  an- 
gular curvature "  as  seen  in 
Pott's  disease.  The  true  curve 
also  exists  in  chronic  rheumatic 
arthritis,  aneur}^sm,  and  malig- 
nant disease.  Hump-back  maybe 
a  marked  feature  of  lateral  curv- 
ature, but  it  is  caused  by  a  projec- 
tion of  the  rotated  spine  and 
distorted  ribs,  and  not  by  the 
spinous  processes.     In  a  case  of 

any  doubt  repeated  examinations  should  be  made,  and  the  case  kept 
under   observation   pending   development. 

Treatnioit. — We  have  seen  in  the  case  of  the  hip-joint  that  if  the 
parts  are  completely  immobilized  in  the  early  stages,  there  is  a  good 
prospect  of  arresting  the  tubercular  process  ;  the  same  may  be  said  of 
Pott's  disease.  Early  and  complete  rest  of  the  diseased  part  is  one  of  the 
most  effectual  means  of  treatment.  But  the  disease  is  full  of  complica- 
tions ;  its  course  is  a  long  one,  and,  whatever  methods  of  cure  are  em- 
ployed, they  must  be  persevered  in  through  months  and  years.  In  the 
early  stages  we  must  aim  to  arrest  the  tuberculous  process  and  bring 
about  resolution  of  the  inflammation  which  has  attacked  the  bone.  De- 
formity must  be  prevented.  In  the  later  stages,  when  deformity  has 
already  occurred,  it  must  as  far  as  possible  be  corrected  ;  bone-destruc- 
tion having  already  taken  place,  we  must  aim  at  a  cure  by  ankylosis ; 
abscesses  are  to  be  evacuated,  sequestra,  if  present,  removed,  and  pres- 
sure upon  the  cord  by  pus,  bone,  or  thickened  dura  averted. 

Rest  is  the  most  valuable  of  all  agencies  in  the  early  stages.     The 


Fig.  237. — Rachitic  posterior  curvature  (from  a 
photograph  in  the  collection  of  Dr.  Gillette). 


538 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


diseased  vcrtebni.'  suffer  from  the  weight  of  the  portion  of  the  trunk 
wliich  hes  above  them,  and  this  weight  it  is  necessary  to  remove. 
This  is  effectually  accomplished  by  placing  the  patient  in  the  recumbent 
position  and  keeping  him  there.  The  mattress  must  be  smooth  and 
hard,  so  as  to  prevent  sagging  of  any  part  of  the  spine.  To  carry  out 
this  measure  thoroughly  the  patient  must  lie  either  upon  his  back  or  his 
face ;  turning  upon  the  side  or  bending  forward  while  lying  on  the  side 


Fig.  238. — Extension  in  the   recumbent  position  (from  a  photograph  in  the  collection  of  Dr. 

Gillette). 

twists  and  flexes  the  spine  and  disturbs  the  parts  which  we  are  trying  to 
keep  at  rest.  When  the  disease  affects  the  cervical  vertebrae,  the  head 
and  neck  should  be  steadied  by  sand-bags  laid  one  on  each  side  and  kept 
in  position  by  tapes.  The  sand-bags  should  extend  from  the  top  of  the 
head  to  the  shoulder.  No  pillows  should  be  used.  Extension  is  a 
valuable  adjunct  to  rest  in  the  recumbent  position.  It  can  be  applied 
to  the  head  and  occiput  by  a  sling  connected  with  a  weight  and 
a  cord  which  runs  over  a  pulley  at  the  head  of  the  bed,  as  shown  in 


Fig.  239. — Frame  to  secure  recumbency  and  fixation  and  to  allow  patient   to  be  moved  about 

(Hoffa). 

Fig.  238.  The  head  of  the  bed  being  raised  to  ensure  counter-exten- 
sion, the  weight  need  not  exceed  one  pound,  or  the  foot  of  the  bed 
can  be  elevated  to  the  extent  of  several  inches,  and  extension  by  Buck's 
method  made  upon  the  lower  limbs. 

Treatment  by  recumbency  is  indicated  where  the  symptoms  are 
acute,  and  especially  when  the  disease  is  in  the  cervical  or  in  the  lower 
lumbar   regions.     It   is  often  effectual  in  preventing  paralysis   or  the 


INJURIES,   DISEASES,  AND  DEFORMITIES   OF   THE  SPINE.     539 


formation  of  an  abscess.  It  also  has  its  disadv^antages,  one  of  the  most 
serious  of  which  is  the  close  confinement  within  doors.  To  obviate 
this  and  to  allow  the  patient  to  be  taken  into  the  open  air  various  con- 
trivances have  been  devised,  one  of  the  simplest  of  which  is  the  frame 
shown  in  Fig.  239.  On  this  frame  he  can  lie  when  in  bed  or  be  carried 
into  the  open  air  without  disturbing  the  spine.  This  treatment  should 
be  persevered  in  until  all  signs  of  the  disease  have  disappeared,  either 
by  resolution  or  by  ankylosis.  Constitutional  treatment  directed 
toward  the  tubercular  condition  should  be  kept  up  throughout.  Sun- 
light, fresh  air,  nourishing  diet,  cod-liver  oil,  phosphates,  and  syrup  of 
the  iodid  of  iron  are  indispensable. 

Trcatuicnt  by  Suspension  and  Piaster  Jackets. — An  endless  variety  of 
appliances  has  been  devised  for  producing  fixation  of  the  spine.  The 
simplest  and  most  practicable  of  these  is  the  plaster  jacket,  for  the 
general  adoption  of  which  we  are  indebted  to  Dr.  Sayre.  This  method 
of  treatment  is  suitable  when  the  disease  is  below  the  mid-dorsal  ver- 
tebrae and  is  not  in  a  very  acute  stage.  The  object  aimed  at  is  to  steady 
the  spine  and  to  transfer  the  weight 
of  the  parts  above  the  disease  to  the 
pelvis  and  hips.  The  spine  is  put 
in  the  best  position  for  receiving 
the  plaster  jacket  by  suspending 
the  patient  in  the  apparatus  shown 
in  Fig.  240.  The  patient  is  stripped 
and  a  closely-fitting  woollen  under- 
shirt put  on.  He  is  then  suspended 
by  means  of  the  chin  and  occiput, 
and  in  the  case  of  older  persons  by 
the  axillary  bands  in  addition.  The 
pulleys  are  used  to  deviate  him  so 
that  the  heels,  and  if  necessary  the 
toes,  leave  the  floor.  The  shirt  is 
now  pulled  down  so  as  to  make  all 
parts  of  it  smooth ;  the  bony  promi- 
nences, such  as  the  iliac  spines  and 
the  crest  of  the  ilium,  are  padded 
with  cotton  ;  and  a  towel,  folded 
into  the  shape  of  a  wedge,  is  placed 
with  its  broad  end  upward  over 
the  abdomen.  This  is  called  the 
dinner  pad,  and  is  to  be  removed 
after  the  application  of  the  jacket, 
so  as  to  leave  a  space  which  will 
permit  the  distention  of  the  abdo- 
men after  eating.  The  bandages 
are  then  applied,  beginning  between 
the  trochanters  and  the  crest  of  the 
ilium  and  extending  to  the  axillae. 
The  most  convenient  size  of  band- 
age is  three  inches  wide  and  six  yards  long,  and  about  three  layers  are 
sufficient.     In  about  fifteen  or  twenty  minutes  after  the  plaster  is   ap- 


FiG.   240.- 


Tripod  for  the  suspension  of  the 
patient  (Sayre). 


540 


SURGICAL    DIAGNOSIS  AND    TREATMENT. 


plied  it  will  have  set,  and  the  patient  can  then  be  lifted  by  the  arms  and 
placed  upon  a  smooth  surface,  where  he  must  lie  for  about  an  hour 
to  allow  the  jacket  to  become  hardened. 

The  jacket,  if  skilfully  applied,  can  be  worn  for  ten  or  twelve  weeks, 
but  should  there  be  any  suspicion  that  an  abscess  is  forming  or  that 
undue  pressure  is  being  exerted  at  any  point,  it  should  be  removed,  the 
parts  carefully  examined,  and  if  found  satisfactory  a  new  jacket  can  be 
applied.  Sometimes  it  is  advisable  to  have  a  removable  jacket.  This 
can  be  done  by  cutting  it  down  the  front,  binding  the  edges  with  adhe- 
sive plaster,  and  inserting  eyelets  at  a  suitable  distance  from  the  edge, 
by  which  it  can  be  laced.  A  ready  and  useful  position  for  receiving  a 
plaster  cast  is  shown  in  Fig.  241. 


Fig.  241. — Position  of  patient  for  receiving  plaster  jacket  (from  a  photograph  in  the  collection 

of  Dr.  Gillette). 

When  the  disease  is  above  the  mid-dorsal  region,  additional  support 
must  be  given  to  the  head  and  neck,  and  this  is  secured  by  the  "jury- 
mast."  It  consists  of  a  vertical  steel  bar  shaped  to  the  curves  of  the 
neck  and  head,  and  attached  to  which  is  the  sling  that  supports  the 
chin  and  occiput  (Fig.  242).  The  lower  end  of  the  bar  can  be  incor- 
porated with  the  plaster  jacket  or  riveted  to  the  leather  or  poroplastic 
jacket.  A  great  variety  of  appliances  can  be  used  instead  of  the  plas- 
ter cast.      A  neat  and  comfortable    support  of  this   kind   is  seen  in 

Fig-  243- 

Treatment  of  CoDiplicatioiis. — The  most  common  and  serious  com- 
plication of  Pott's  disease  is  spinal  abscess.  The  abscesses  which  form  in 
the  lumbar  and  iliac  regions  are  probably  the  most  dangerous  and  most 
uncertain  in  their  course.  When  an  abscess  has  formed  it  should  not 
be  temporized  with  by  aspiration,  for  this  has  been  thoroughly  tried 
and  found  wanting.  Two  methods  of  treatment  deserve  attention  : 
First.  Tapping  and  injection  of  iodoform  emulsion.  When  the  abscess- 
cavity  can  be  wholly  evacuated  and  the  emulsion  made  to  penetrate 
every  part   of  it,  this  form  of   treatment  is   fairly  successful.     Many 


INJURIES,   DISEASES,   AND  DEFORMITIES   OF   THE  SPINE.     54I 

abscesses,  however,  burrow  through  the  tissues  and  appear  in  situ- 
ations far  removed  from  their  starting-point,  and  nothing  but  con- 
tinuous drainage  will  effect  total  removal  of  the  fluid.  Second.  Free 
evacuation  and  drainage.  The  treatment  wall  depend  upon  the  situ- 
ation. Retropharyngeal  abscess  was  formerly  opened  by  way  of  the 
mouth,  the  incision  being  made  a  little  to  one  side  of  the  middle  line 
and  by   means   of  a   long  straight   bistouiy.      The   objection   to   this 


Fig.  242. —  Jury-mast  and  leather  jacket  (Gillette). 


method  is  that  the  tubercular  fluid  is  almost  sure  to  become  infected, 
and  true  suppuration  is  thus  added  to  the  tubercular  process.  An 
external  opening  should  be  made  when  possible,  and  infection  pre- 
vented by  the  strictest  aseptic  treatment.  The  incision  can  be  made 
at  either  border  of  the  sterno-mastoid  muscle,  and  the  abscess  reached 
by  dissection,  care  being  taken  to  avoid  the  great  vessels.  When  the 
abscess  is  in  the  dorsal  or  lumbar  region,  it  should  be  laid  freely  open 
and  explored  with  the  finger  in  search  of  sequestra  or  outlying  pockets. 


542 


SUKGICAL    DIAGNOSIS  AXD    TREAIMENT. 


Psoas  abscess  is  generally  a  double  abscess,  divided  in  the  middle 
by  PoLipart's  ligament.  The  upper  cavity  is  usually  much  the  larger, 
and  for  these  reasons  it  is  difficult  to  drain.  The  opening  should  always 
be  made  in  the  l^ynbar  region.  An  incision  is  made  along  the  outer 
edge  of  the  e're^-^^^pin;i,'  muscle,  and  all  the  structures  divided  down 
to  the  quadratuS^imborum  ;  the  tip  of  the  third  lumbar  transverse 
process  is  sought  for,  and  opposite  to  this  the  fibers  of  the  quadratus 
and  the  anterior  layer  of  the  transversalis  fascia  are  divided.  The 
finger  is  then  passed  along  the  anterior  surface  of  the  quadratus  until 


Fig.  243. 


-Antero-posterior  support  for  Pott's  disease  in  the  lower  dorsal  region  (from  a  photo- 
graph in  the  collection  of  Dr.  Gillette). 


the  psoas  and  the  abscess  are  reached.  A  second  opening  is  usually 
required  where  the  abscess  points.  If  a  drainage-tube  can  be  made  to 
connect  these  two  openings,  so  much  the  better. 

Paralysis. — If  proper  treatment  be  adopted  in  the  early  stages  of 
the  disease  and  faithfully  persevered  in,  paralysis  will  seldom  occur,  and 
even  if  it  be  present  when  the  case  comes  under  the  care  of  the  sur- 
geon, the  prognosis  need  not  be  unfavorable :  most  excellent  results 
have  been  obtained  by  rest  in  the  recumbent  posture,  and  especially 
when  combined  with  extension.  When  these  means  fail  and  the  paral- 
ysis is  steadily  increasing,  the  operation  of  laminectomy  may  be  con- 


DISEASES  AND   INJURIES   OF  NERVES.  543 

sidered,  with  the  idea  of  relieving  pressure  on  the  cord  and  possibly 
removing  the  diseased  bone.  The  operation  is  open  to  serious  objec- 
tions, and  is  only  justifiable  when  under  other  treatment  the  paralysis 
continues  to  increase,  especially  that  of  the  bladder  and  rectum  (Kraske). 


CHAPTER  X. 

DISEASES    AND    INJURIES   OF    NERVES. 

A  NERVE,  be  it  large  or  small,  is  composed  of  the  following  parts  : 
I.  A  nerve-sheath  or  perineurium  ;  2.  A  lymph-space  between  the 
perineurium  and  the  nerve  proper ;  3.  The  endoneurium,  composed  of 
offsets  from  the  perineurium,  which  pass  to  the  interior  of  the  nerve 
and  there  form  the  sheaths  which  surround  bundles  of  primitive  nerve- 
tubules  ;  4.  Blood-vessels;   5.  Ner\i  nervorum. 

Neuritis,  or  Inflammation  of  a  Nerve. — When  a  nerve  becomes 
inflamed,  one  of  the  first  changes  is  an  increase  in  the  connective  tissue 
of  the  sheath  or  perineurium,  which  is  further  thickened  and  swollen 
by  exudation  of  serum.  Changes  in  the  nerve-tubules  rapidly  follow ; 
they  undergo  granular  and  fatty  degeneration  and  are  consequently 
softened.  In  rare  cases  suppuration  occurs  in  the  nerve-structure,  and 
occasionally  hemorrhage. 

When  inflammation  takes  the  chronic  form,  the  sheath  becomes 
permanently  thickened  and  adherent  to  surrounding  tissues.  By  pres- 
sure it  produces  atrophy  of  the  nerve-fibers,  which  disappear  to  a  great 
extent. 

Inflammation  of  a  nerve  may  be  idiopathic,  but  its  most  common 
causes  are  injury  and  exposure  to  cold.  Certain  diseases  also  give  rise 
to  it,  such  as  gout,  rheumatism,  syphilis,  typhoid  fever,  and  the  exan- 
themata. The  nerves  most  commonly  affected  are  the  sciatic  and  the 
facial.  Many  of  the  cases  of  sciatica  and  of  facial  neuralgia  are  really 
due  to  inflammation  of  the  nerve.     Neuritis  may  be  acute  or  chronic. 

Syviptouis. — These  are  constitutional  and  local.  Unless  the  neuritis 
is  severe  and  extensive  the  constitutional  signs  may  be  wanting.  When 
present  they  are  rigors,  high  temperature  and  pulse,  with  delirium  in 
exceptional  cases.  The  local  symptoms  are  much  more  important  and 
constant : 

I.  Acute  Neuritis. — The  earliest  indication  of  acute  neuritis  is  gen- 
erally an  aching  pain  along  the  course  of  the  nerve,  worse  at  night  and 
increased  by  movement  of  the  part.  By  digital  pressure  the  nerve- 
trunk,  if  superficial,  may  be  felt  to  be  enlarged  and  exquisitely  tender, 
while  in  rare  cases  the  skin  over  it  is  streaked  with  redness.  The  pain 
radiates  over  the  parts  to  which  the  nerve  is  distributed ;  the  sensation 
may  be  a  tingling  or  numbness,  a  dull  aching  or  burning.  The  muscles, 
sooner  or  later,  show  the  effect  of  disturbance  of  the  nerve-current.  The 
w^iole  of  a  muscle  or  certain  of  its  fasciculi  may  be  thrown  into  contrac- 
tion. This  contraction  may  take  the  form  of  twitching,  but  tonic  spasm 
is  more  common.    At  a  later  period  the  muscle  loses  its  power,  respond- 


544  SC'KGICAL    DIAGjyOSIS  AXD    TREATMENT. 

ing  imperfectly  to  the  faradic  current,  and  in  unfavorable  cases  advancing 
to  complete  paralysis  and  atrophy.  When  the  neuritis  is  of  traumatic 
origin  it  has  a  tendency  to  extend  along  the  course  of  the  nerve  until 
it  reaches  the  branches.  These  in  their  turn  become  involved,  and  so 
the  ner\cs  of  an  entire  limb  may  be  affected.  From  this  condition  the 
inflammation  may  subside,  leaving  no  ill  effects,  or  the  disease  may  be- 
come chronic,  the  muscles  wasted,  the  joints  stiffened,  and  the  general 
health  impaired  from  prolonged  suffering. 

Diagnosis. — Rheumatism  and  neuralgia  are  sometimes  difficult  to 
distinguish  from  neuritis.  The  pain  of  neuritis  follows  the  track  of  a 
nerve,  and  in  confirmed  cases  there  are  sensory,  motor,  and  trophic 
changes.  Neuralgia  is  recognized  by  the  absence  of  febrile  symptoms 
and  by  the  more  diffuse  character  of  the  pain. 

2.  Chronic  nvnritis  is  often  a  sequel  of  the  acute  form.  The  sheath 
of  the  nerve  becomes  thickened  and  adherent  to  the  surrounding  tis- 
sues ;  the  nerve  atrophies,  and  may  even  disappear.  The  whole  nerve 
is  increased  in  size,  but  in  the  advanced  stages  it  shrinks  to  less  than  its 
normal  diameter. 

Multiple  neuritis  is  associated  with  alcoholism  and  syphilis,  but  it 
possibly  arises  from  the  same  conditions  which  produce  simple  acute 
or  chronic  neuritis.  As  a  rule,  it  begins  on  the  extensor  surface  of  the 
legs.  From  feet  and  hands  it  spreads  to  various  parts  of  the  body. 
Tenderness  and  redness  of  the  skin  along  the  course  of  the  nerves  are 
characteristic,  and  the  nerves  can  frequently  be  felt  as  firm  cords.  The 
muscles  lose  their  power  and  begin  to  waste,  the  reflexes  disappear,  and 
the  movements  simulate  those  of  locomotor  ataxia.  The  course  of  the 
disease  varies.  In  some  cases  improvement  takes  place,  but  in  others 
the  condition  goes  on  from  bad  to  worse,  until  the  spinal  cord  becomes 
invoh^ed  or  the  patient  dies  of  some  intercurrent  disease.  The  difficulty 
in  diagnosis  is  to  distinguish  it  from  tabes  dorsalis.  There  may  be 
lightning  or  girdle  pains  and  ataxic  gait,  but  in  spinal  disease  the  mus- 
cles respond  normally  to  the  electric  current,  while  in  multiple  neuritis 
they  do  not. 

Treatment. — The  first  essential  in  the  treatment  is  absolute  rest.  In 
the  case  of  the  nerves  of  a  limb  this  can  be  best  secured  by  the  appli- 
cation of  a  splint.  When  due  to  rheumatism,  syphilis,  or  other  dis- 
eases these  must  receive  proper  attention.  For  the  relief  of  the  acute 
pain  warm  fomentations,  belladonna  liniment,  or  the  subcutaneous 
injection  of  morphin  are  indicated.  After  the  acute  symptoms  subside 
iodin,  blisters,  and  acupuncture  are  useful  remedies,  but  best  of  all 
is  the  constant  galvanic  current.  Hot  or  Turkish  baths  at  night  often 
secure  sleep.  The  constitutional  remedies  most  to  be  relied  upon  are 
quinin,  salicylic  acid,  iron,  and  tonics.  Nerve-stretching  has  met  with 
varying  success,  and  undoubtedly  has  proven  beneficial  in  many  cases. 
When  there  is  much  hyperemia,  or  in  the  rare  instances  in  which  there 
is  suppuration  in  the  nerve-sheath,  the  nerve  should  be  cut  down  upon 
and  the  sheath  laid  freely  open. 

Neuralgia  signifies  pain  in  a  nerve.  It  is  of  an  acute  paroxysmal 
character,  coming  on  suddenly,  and  as  suddenly  disappearing.  Many 
of  the  cases  diagnosed  as  neuralgia  are  really  neuritis.  It  is  only  when 
the  symptoms  of  inflammation  are  wanting,  and  when  there  is  an  ab- 


DISEASES  AND   INJURIES   OF  NERVES.    ^  54$ 

sence  of  disease  or  injury  to  the  parts  supplied  by  the  affected  nerve, 
that  we  are  justified  in  pronouncing  the  pain  neuralgic.  In  a  very 
large  number  of  cases  the  cause  is  unknown.  The  following,  however, 
may  be  set  down  as  among  the  most  frequent  causes :  i.  Injury  to  the 
nerve,  often  obscure  ;  2.  Irritation  by  a  foreign  body ;  3.  Pressure  of  a 
tumor;  4.  Compression  by  a  cicatrix;  5.  Certain  toxic  conditions  of 
the  blood,  as  in  malaria,  lead-poisoning,  or  mercury-poisoning  ;  6.  Over- 
distention  of  veins  near  nerves  as  they  pass  through  long  bony  canals, 
as  in  the  intraorbital  canal ;  7.  In  some  instances  the  neuralgia  is  reflex, 
irritation  in  one  nerve  producing  pain  in  another. 

Symptoms. — Pain  of  a  burning,  cutting,  darting,  or  boring  character 
along  the  course  of  a  nerve,  continuous,  remittent,  or  intermittent,  is 
the  most  prominent  symptom.  Pressure,  as  a  rule,  increases  the  pain, 
but  in  some  cases  gives  relief  From  a  surgical  standpoint  neuralgia 
is  seen  chiefly  in  three  forms  :  (i)  neuralgia  of  the  trifacial  nerve  or  tic- 
douloureux  ;  (2)  sciatica ;  (3)  the  neuralgia  of  stumps  and  scars. 

Tic-douloureux  may  be  confined  to  one  or  all  of  the  branches  of  the 
fifth  pair,  and  is  often  attended  with  the  most  excruciating  pain.  The 
slightest  cause,  such  as  a  draft  of  cold  air,  a  slight  touch,  or  a  loud 
noise,  may  suffice  to  bring  on  a  paroxysm.  The  movements  of  masti- 
cation are  likely  to  start  up  the  pain,  so  that  the  patient  is  in  dread 
every  time  he  eats. 

Sciatica  is  a  painful  and  common  affection.  It  is  frequently  a 
functional  neurosis,  but  autopsies  have  shown  that  in  some  cases  it  is 
an  organic  disease  characterized  by  softening  of  the  nerve-tissue,  dila- 
tation of  the  vessels,  and  exudation  of  serum  into  the  sheath.  In  cases 
due  to  functional  neurosis  no  anatomical  changes  are  found. 

For  diagnostic  purposes  it  is  convenient  to  divide  sciatica  into  three 
varieties:  i.  Sciatic  neuralgia;  2.  Sciatic  neuritis;  3.  Symptomatic 
sciatica — /.  e.  sciatica  which  is  the  result  of  some  other  disease. 

Symptoms. — Pain  is  the  leading  symptom.  It  is  usually  worse  at 
night,  and  in  some  cases  this  appears  to  be  because  the  patient  cannot 
bear  to  extend  the  leg  while  in  bed.  During  the  day  there  is  less  suf- 
fering, especially  if  the  patient  remains  quiet ;  but  standing  or  walking 
speedily  aggravates  the  pain.  Tenderness  can  generally  be  detected  at 
the  four  following  points :  the  sciatic  notch,  the  lower  margin  of  the 
gluteus  maximus,  the  popliteal  space,  and  the  head  of  the  fibula. 

When,  even  after  years  of  suffering,  the  disease  produces  no  atrophy 
of  the  muscles  of  the  limb  (except  what  we  might  naturally  expect 
from  want  of  use),  we  may  safely  assume  that  the  disease  is  of  the 
neurotic  type.  If  there  be  a  iiairitis,  trophic  changes  will  develop, 
especially  atrophy  of  the  muscles  with  reaction  of  degeneration  (Nonue). 
The  patellar  reflex  is  diminished.  Double  sciatica  is  very  significant  of 
spinal  disease  or  of  general  disease  of  the  nervous  system,  as  tabes,  or 
it  may  be  associated  with  syphilis  or  diabetes.  The  urine  should  be 
examined  for  sugar.  "  It  has  been  shown  by  Braun  and  others  that 
sciatica  may  react  upon  the  vaso-motor  nerves  and  cause  a  small 
amount  of  sugar  to  appear  in  the  urine,  which  may  subside  as  the 
pain  ceases  to  be  troublesome.  Robson  Roose  reports  3  cases  in 
which  this  symptom  was  present.  If,  then,  we  find  sugar  in  the  urine, 
two  things  may  enable  us  to  determine  whether  the  sciatica  is  a  cause 
35 


546  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

or  a  symptom — viz.  the  knowledge  as  to  whether  any  sugar  was 
present  before  the  appearance  of  the  sciatica,  and  inquiry  as  to  the 
amount  of  sugar  present,  and  whether  it  is  controlled  by  the  cause 
of  the  sciatica."  ' 

Neuralgia  of  scars  may  be  divided  into  two  classes.  In  one  form 
there  is  localized  pain,  excited  by  pressure  on  a  particular  spot,  and 
there  can  generally  be  felt  an  induration  or  adhesion  of  the  scar  to  the 
underlying  bone.  In  the  other  form  the  pain  is  more  widely  diffused, 
attentled  with  superficial  hyperesthesia,  intermittent  in  character  and 
accompanied  by  jerkings.  This  form  is  found  in  anemic  individuals, 
mostly  women,  and  is  of  constitutional  origin,  while  the  first  is  purely 
local.  The  importance  of  diagnosticating  between  these  two  forms  is 
that  the  local  variety  can  be  best  treated  by  operation,  while  the  con- 
stitutional form  will  not  be  benefited  until  the  system  is  put  into  better 
condition.  In  a  case  of  this  kind  mentioned  by  Moullin  amputation 
was  resorted  to  four  consecutive  times,  and  the  nerves  stretched  almost 
to  the  point  of  tearing  them  out  of  the  stump,  and  still  the  pain  con- 
tinued. 

Treatviciit. — When  the  cause  can  be  discovered  its  removal  is  the 
first  point  in  treatment.  If  the  disease  is  due  to  malaria,  quinin  is 
indicated,  large  doses  often  being  required.  When  there  is  anemia  iron 
should  be  employed.  In  the  majority  of  cases  the  suffering  can  be 
relieved  by  full  doses  of  quinin,  acetanilid,  phenacetin,  chloral,  or 
morphin,  while  applications  of  aconite,  belladonna,  veratria,  or  menthol 
can  be  used  locally.  The  general  health  should  in  all  cases  be  im- 
proved by  tonics,  fresh  air,  and  easily  digested  food.  In  sciatic  neur- 
algia subcutaneous  nerve-stretching  is  indicated  when  ordinary  means 
fail.  The  patient  is  put  under  an  anesthetic,  and  while  the  leg  is  kept 
in  full  extension  the  thigh  is  forcibly  flexed  upon  the  body.  Stretching 
of  the  nerve  through  an  incision  has  a  more  marked  effect,  probably 
from  the  fact  that  adhesions  of  the  nerve  and  its  sheath  are  more  com- 
pletely broken  up. 

Epileptiform  neuralgia  is  another  form  requiring  careful  study.  It 
often  resists  every  form  of  treatment  except  operative,  and  even  that 
often  produces  only  temporary  benefit.  It  is  distinguished  from  other 
forms  by  the  twitching  of  the  facial  muscles.  The  teeth  may  be  ex- 
tracted, one  by  one,  without  affording  a  particle  of  relief  Morphia 
only  makes  the  condition  of  the  patient  worse  and  worse,  and  other 
anodynes  are  useless.  Galvanism,  persistently  employed,  will  benefit 
some  cases. 

Nerve-stretching  has  had  its  advocates,  and  many  satisfactory  results 
are  reported.  When  the  superior  maxillary  is  the  branch  involved, 
excision  of  Meckel's  ganglion  is  a  justifiable  procedure,  although  even 
after  this  formidable  operation  the  relief  obtained  will  not  probably  last 
more  than  a  few  months.  The  ganglion  can  be  reached  and  excised 
from  the  front  by  trephining  the  antrum.  A  crucial  excision  over  the 
infra-orbital  foramen  is  made  down  to  the  bone.  From  immediately 
below  the  foramen  a  half-inch  disk  is  removed  by  a  trephine.  The 
nerve  is  then  traced  back  to  the  posterior  wall.  Through  this  wall  a 
second  trephine  opening  is  cautiously  made  and  the  ganglion  is  ex- 

1  Dr.  D.  O.  Thomas  :   Pacific  Med.  Joiirn.,  1895. 


DISEASES  AND   INJURIES   OF  NERVES.  547 

posed.  The  ganglion  should  be  removed,  together  with  its  posterior 
dental  branches,  and  the  whole  of  the  infra-orbital. 

When  the  inferior  dental  is  the  nerve  involved,  it  can  best  be  reached 
by  the  mouth,  and  operation  in  this  region  has  the  advantage  of  leaving 
no  unsightly  scar.  Having  first  inserted  a  gag  and  forced  the  mouth 
as  widely  open  as  possible,  make  an  incision  along  the  projecting  fold 
of  mucous  membrane  which  passes  from  one  jaw  to  the  other  behind 
the  last  molar  tooth.  By  pushing  the  finger  between  the  internal  ptery- 
goid muscle  and  the  ramus  the  sharp  spine  of  bone  can  be  felt  which 
is  the  landmark  for  the  orifice  of  the  dental  canal.  A  blunt  hook  or  an 
aneurysm  needle  is  then  used  to  draw  the  nerve  forward,  when  it  can 
be  separated  from  its  attachments  and  divided. 

Injuries  of  Nerves. — Although,  as  a  rule,  nerves  are  well  pro- 
tected, they  nevertheless  are  liable  to  a  variety  of  injuries.  Tumors 
may  compress  a  nerve,  as,  for  instance,  aneurysm  of  the  aorta  pressing 
upon  the  recurrent  laryngeal.  In  dislocation  of  the  shoulder  the  head 
of  the  humerus  may  compress  and  contuse  the  brachial  plexus.  When 
fracture  occurs,  one  of  the  fragments  may  compress  and  even  lacerate 
a  neighboring  nerve.  A  drunken  man  falling  asleep  with  his  arm  over 
the  back  of  a  chair  has  had  the  limb  paralyzed  from  pressure  upon  the 
brachial  plexus.  The  pelvic  nerves  are  frequently  injured  from  long- 
continued  pressure  during  delivery,  and  the  seventh  nerve  of  the  child 
has  been  injured  during  the  application  of  forceps,  with  facial  palsy  as 
a  result. 

Svinptoms. — Compression  or  contusion  of  a  nerve  is  recognized  by 
the  tingling  sensation,  which  is  commonly  spoken  of  as  "  pins  and 
needles."  In  more  severe  contusions  the  functions  of  the  nerves  may 
be  lost  and  more  or  less  marked  paralysis  be  manifested,  or  a  neuritis 
may  be  developed  along  the  course  and  distribution  of  the  nerve.  Much 
information  can  be  gained  by  the  employment  of  the  faradic  current. 
Should  the  muscles  respond  readily,  the  injury  is  probably  slight. 
Should  there  be  no  response  and  should  the  muscles  begin  to  atrophy 
and  degenerate,  the  prognosis  is  unfavorable. 

Treatment. — Removal  of  the  cause,  when  possible,  is  the  first  indi- 
cation. To  restore  the  function  of  the  nerve  absolute  rest  is  of  the 
utmost  importance.  In  the  case  of  a  limb  complete  immobilization  by 
a  splint  is  good  treatment.  When  pain  is  intense  hypodermic  injections 
of  morphin  and  atropin  will  be  required.  In  prolonged  and  obstinate 
cases  arsenic  and  the  use  of  the  galvanic  current  will  prove  valuable 
remedies. 

Wounds  of  Nerves. — A  nerve  may  suffer  complete  division  or 
it  may  be  only  lacerated.  In  many  cases  it  is  a  complication  of  a  large 
wound  which  divides  other  structures.  It  is  very  important  to  bear  in 
mind  that  when  a  nerve  is  severed  degenerative  changes  immediately 
begin,  hence  the  importance  of  uniting  the  divided  ends  of  a  nerve  at  the 
earliest  possible  moment.  Indeed,  it  is  just  as  important  to  perform  this 
operation  as  to  approximate  the  fragments  of  a  broken  bone.  Common 
causes  of  nerve-wounds  are  fragments  of  glass,  gunshot  wounds,  and 
punctured  wounds  produced  by  knives,  scissors,  needles,  or  splinters 
of  wood. 

Symptoms. — The  best  evidence  of  all  is  afforded  when  the  divided 


548  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

or  partially  divided  nerve  is  visible  in  the  wound.  In  many  cases  the 
wound  is  small  or  punctured  and  we  cannot  see  the  nerve.  Diagnosis 
must  then  rest  upon  the  effects  produced,  not  only  upon  the  nerve  itself, 
but  upon  the  area  to  which  it  is  distributed.  These  may  be  considered 
as  immediate  and  remote  : 

I.  Ivuncdiatc  Effects. — Pain  is  of  varying  significance.  In  some 
cases  it  is  so  slight  as  to  be  scarcely  noticeable ;  in  others,  even  when 
the  nerve  is  small,  the  suffering  is  so  intense  as  to  produce  profound 
shock.  Such  a  condition  is  common  in  gunshot  wounds.  A  marked 
s}-mptom  immediately  after  the  injury  is  anesthesia,  and  in  most  cases 
it  can  be  traced  over  the  parts  supplied  by  the  nerves  in  question.  At 
the  same  time  too  much  reliance  must  not  be  placed  upon  this  evidence, 
for  it  is  possible  to  find  sensation  remaining  after  complete  division  of 
a  nerve-trunk. 

Blindfold  the  patient  and  place  the  limb  at  full  extension  on  a  firm 
support,  so  that  no  vibration  can  be  communicated.  Tactile,  thermic, 
and  electrical  stimuli  can  then  be  successively  applied  and  their  effects 
carefully  noted.  For  the  examination  of  tactile  sensation  a  light  touch, 
such  as  that  communicated  by  a  pencil,  a  feather,  or  a  pin,  may  be 
used.  The  esthesiometer  is  an  instrument  for  testing  sensation,  and 
consists  simply  of  a  pair  of  compasses  fitted  with  a  graduated  scale 
which  measures  the  distance  to  which  the  two  points  are  separated. 
An  ordinary  pair  of  dividers  will  answer  the  purpose.  In  using  the  in- 
strument care  must  be  taken  to  touch  the  skin  at  the  two  points 
simultaneously,  and  each  time  the  result  must  be  compared  with  the 
corresponding  part  on  the  opposite  side  of  the  body.  The  test  is  to 
ascertain  the  ability  of  the  patient  to  distinguish  the  ends  of  the  instru- 
ment as  two  points  or  as  one.  Different  parts  of  the  body  in  health 
give  different  results  when  thus  tested.  At  the  end  of  the  finger  two 
points  can  be  recognized  when  the  distance  between  them  is  only  2  to 
2\  mm.,  while  on  the  back  40  to  70  is  the  minimum.  A  difference 
\y'A\  also  be  observed,  depending  upon  whether  the  instrument  is  placed 
transversely  or  longitudinally  to  the  axis  of  the  limb.  In  a  typical 
case  three  areas  can  be  distinguished  :  {a)  the  area  of  anesthesia  (total 
loss  of  sensation) ;  {b)  the  area  of  paresthesia  (partial  loss  of  sensation)  ; 
(yC)  the  area  of  normal  sensation.  In  some  cases  there  is  observed  an 
area  of  supplementary  sensation.  This  is  where  a  nerve-trunk  is 
divided  and  its  current  cut  off,  yet  sensation  is  not  impaired.  It  has 
been  explained  on  the  theory  that  the  nerves  anastomose,  and  the 
nerve-current  is  maintained  just  as  the  collateral  circulation  in  the  case 
of  a  divided  arter)\  In  studying  a  case  it  is  customary  to  mark  the 
area  of  total  anesthesia  by  a  dark  shading,  while  that  of  partial  anes- 
thesia is  indicated  by  a  lighter  shade. 

Having  completed  the  examination  by  the  sense  of  touch,  other 
stimuli  may  be  employed.  Heat  is  used  by  taking  a  sponge  and  dip- 
ping it  in  hot  water  or  by  placing  the  limbs  in  water  of  a  known  tem- 
perature. A  very  simple  and  ready  method  is  to  first  breathe  upon  the 
part  and  then  gently  blow  upon  it.  If  more  accuracy  is  desired,  the 
thermesthesiometer  can  be  employed.  It  consists  of  two  cylindrical 
wooden  vessels  with  metal  buttons,  into  which  water  of  differing  tem- 
peratures is  poured  ;  a  thermometer  in  each  registers  the  degree  of  heat. 


DISEASES  AND   INJUR] ES   OF  NERVES.  549 

Two  test-tubes  can  be  utilized  in  the  same  manner.  Lastly,  electricity  is 
employed.  When  tactile  and  thermic  stimuli  fail  the  nerves  will  often 
respond  to  the  electric  brush. 

Examination  as  to  loss  of  motion  is  much  simpler.  In  the  case  of 
the  forearm  the  patient  is  asked  to  grasp  the  hands  of  the  surgeon, 
when  any  difference  of  muscular  power  is  readily  detected.  Any  given 
group  of  muscles  may  be  tested  by  asking  the  patient  to  use  the  mus- 
cles while  the  examiner  resists  the  movement. 

Reflex  paralysis  is  a  very  interesting  phenomenon  observed  in  some 
cases.  Wound  of  a  nerve  in  the  lower  extremity  may  produce  paral- 
ysis of  the  opposite  limb,  or  even  of  both  limbs  on  the  opposite  side. 
This  has  been  explained  on  the  theory  that  the  nerve-centers  of  motion 
and  sensation  have  become  exhausted. 

2.  Remote  Effects. — To  the  observations  of  Drs.  Mitchell,  Morehouse, 
and  Keen  during  the  American  Civil  War  we  are  indebted  for  much 
valuable  knowledge  on  this  point.  Loss  of  motion  is  more  marked  and 
more  persistent  than  loss  of  sensation.  The  muscles  soon  show  signs  of 
weakness  and  wasting,  which  steadily  increase  to  the  degree  of  com- 
plete palsy.  Gradual  and  steady  contraction  is  observed  in  some  cases, 
and  deformity  is  the  result.  The  changes  in  sensation  are  marked  by 
anesthesia,  or  it  may  be  hyperesthesia  or  intense  pain.  In  the  area 
supplied  by  the  nerve,  and  at  a  distance  from  the  seat  of  injury,  cha- 
racteristic changes  may  be  observed.  The  skin  has  an  appearance  as 
if  varnished.  It  is  generally  red  and  dry,  or  it  may  secrete  an  acid, 
foul-smelling  perspiration.  The  hair  of  the  part  becomes  scanty  and  the 
nails  curve  in  both  directions.  Sometimes  ulceration  takes  place  under 
and  around  the  nail,  and  even  gangrene  of  the  ends  of  the  digits  has 
been  observed.  A  peculiar  burning  pain  has  been  described  by  Mitchell 
under  the  name  of  "  causalgia."  So  exquisite  is  the  sensibility  in  this 
condition  that  even  to  point  at  the  limb  so  affected  causes  the  patient 
to  draw  away  in  terror.  Keeping  the  part  cool  and  moist  relieves  the 
causalgia,  and  patients  often  wrap  the  hand  in  a  moist  handkerchief  or 
wear  a  glove  which  is  kept  constantly  wet.  In  certain  cases  eruptions 
resembling  chilblains  or  eczema  are  observed. 

One  of  the  most  striking  effects  of  nerve-degeneration  is  perforating 
ulcer  of  the  foot.  It  is  observed  in  leprosy,  in  locomotor  ataxia,  in 
fracture  of  the  spine,  but  it  may  occur  when  there  is  nerve-degeneration 
from  any  cause.  The  ulcer  is  painless  and  usually  attracts  httle  atten- 
tion. It  begins  as  a  corn,  the  center  of  which  breaks  down,  forming  a 
small  opening.  It  may  remain  small  in  circumference,  but  if  a  probe 
be  inserted  it  will  be  found  to  pass  deeply  into  the  tissues  or  the  meta- 
tarso-phalangeal  articulation.  Placing  the  foot  in  an  elevated  position 
and  enjoining  perfect  rest  will,  in  most  cases,  effect  a  speedy  cure.  The 
ulcer  is  liable  to  recur,  however,  as  soon  as  the  patient  resumes  the  use 
of  the  limb. 

Treatment. — In  any  wound  in  the  vicinity  of  a  nerve-trunk  a  careful 
examination  should  be  made  of  the  divided  tissues.  If  the  nerve  is 
found  to  be  severed,  its  two  ends  should  be  brought  together  in  as  close 
apposition  as  possible  and  united  by  chromicized  catgut  or  fine  silk. 
In  the  case  of  small  nerves  the  suture  must  pass  through  the  substance 
of  the  nerve.     When  the  trunk  is  large  the  sheath  should  be  sutured 


550  SURGICAL  DIAGNOSIS  AND    TREATMENT. 

as  well.  The  needle  should  be  round  and  as  small  as  possible.  Per- 
fect immobilization  of  the  limb  on  a  splint  is  necessary,  and  the  wound 
must  be  treated  with  strict  asepsis.  In  favorable  cases  the  function  of 
the  nerve  is  restored  with  remarkable  rapidity ;  in  others  it  may  be 
long  delayed.  The  time  varies  from  two  days  to  many  months. 
Sensation  is  the  first  to  return.  In  cases  of  long  standing  the  prox- 
imal end  of  the  nerve  becomes  bulbous,  while  the  distal  end  is 
slightl}'  changed.  After  dissecting  out  the  divided  ends  of  the  nerve 
the  bulbous  portion  must  be  removed  and  a  small  portion  cut  off  the 
distal  end.  They  can  then  be  stretched  sufficiently  to  bring  their  freshly- 
cut  surfaces  together  and  sutured  as  already  described. 

When  the  ends  are  so  widely  separated  that  they  cannot  be  brought 
together  with  a  moderate  degree  of  stretching,  one  of  several  methods 
may  be  resorted  to.  One  of  the  ends  of  the  severed  nerve  may  be 
split  for  a  certain  distance,  and  the  nerve-flap  turned  over  to  bridge  the 
intervening  space.  The  space  has  been  bridged  across  by  catgut 
sutures  with  the  idea  of  furnishing  a  "  scaffolding  "  along  which  the 
new  nerve-tissue  may  be  reproduced.  This  method  has  not  fulfilled 
the  hopes  formed  of  it. 

Transplantation  of  a  section  of  nerve  has  been  fairly  successful. 
This  is  done  by  taking  a  piece  of  nerve  from  one  of  the  lower  animals, 
accurately  fitting  it  to  the  breach,  and  stitching  it  there,  or  the  nerve 
can  be  removed  from  a  freshly  amputated  limb. 

Injuries  of  Special  Nerves.  —  i.  Facial.  —  The  intra-cranial 
lesions  of  this  nerve  have  already  been  referred  to.  The  injuries  which 
affect  the  nerve  after  it  has  left  the  Fallopian  canal  (extra-cranial 
lesions)  are  of  great  importance  and  of  common  occurrence. 

The  nerve  may  suffer  injury  by  gunshot  wounds  or  other  trauma- 
tisms, but  the  paralysis  of  this  nerve  most  frequently  met  with  is  due 
to  the  influence  of  cold,  and  is  sometimes  called  the  rheumatic  form. 
A  person  who  is  exposed  to  a  draft  of  cold  air,  as  in  sitting  by  an  open 
window  or  travelling  in  an  open  carriage  and  exposed  to  a  strong  side 
wind,  or  passing  from  a  heated  room  into  the  extreme  cold  of  a  winter's 
night,  is  surprised  after  a  few  hours  to  find  that  the  appearance  of  his 
face  is  changed  in  a  remarkable  manner.  He  can  only  wrinkle  one 
side  of  his  brow ;  one  eye  remains  open  in  spite  of  his  efforts  to  close 
it ;  he  cannot  whistle,  for  in  attempting  to  do  so  one  side  of  his  mouth 
is  properly  puckered,  while  the  other  just  forms  a  loop  ;  the  mouth  is 
drawn  to  the  sound  side.  While  eating  the  food  gets  between  the 
cheek  and  the  teeth  on  the  affected  side,  and  has  to  be  removed  with 
the  finger. 

The  diagnosis  must  settle  the  following  points  : 

1.  The  Side  of  the  Face  which  is  Affected. — This  question  may  seem 
superfluous,  but  there  are  cases  in  which  care  is  necessary  before  coming 
to  a  decision.  In  old  persons  the  skin  is  so  wrinkled  and  inelastic  that 
the  muscles  of  the  sound  side  cannot  alter  the  expression,  and  the  only 
change  in  appearance  is  a  rounded,  more  youthful  expression  on  the 
paralyzed  side. 

2.  The  Part  of  the  Nerve  Involved. — When  the  paralysis  is  due  to 
an  intra-cranial  lesion  there  is  facial  paralysis,  but  there  is  something 
more,  such  as  disturbance  of  the  sense  of  hearing  and  of  taste,  paraly- 


DISEASES  AND   INJURIES   OF  NERVES.  55  I 

sis  of  the  velum  palati,  etc.     The  following  points,  formulated  by  Hirt 
and  based  upon  Erb's  diagram,  will  aid  us : 

"  {a)  If  the  lesion  be  between  the  exit  of  the  facial  stem  (from  the 
pons)  and  the  geniculate  ganglion,  we  shall  find  a  paralysis  of  the 
velum  palati,  abnormal  acuteness  of  hearing,  and  diminished  salivary 
secretion. 

"  (/;)  If  the  facial  be  affected  in  the  region  of  the  geniculate  ganglion 
itself,  then  we  find,  in  addition  to  the  just-mentioned  symptoms,  altera- 
tions in  the  sense  of  taste. 

"  {c)  A  lesion  between  the  geniculate  ganglion  and  the  stapedius 
nerve  produces  the  symptoms  described  in  {a)  and  (/^),  but  no  abnor- 
mality of  the  velum  palati. 

"  \d)  A  lesion  between  the  origin  of  the  nerve  to  the  stapedius 
muscle  and  the  giving  off  of  the  chorda  tympani  give  alterations  in 
the  sense  of  taste  and  diminished  salivary  secretion,  but  no  abnormality 
of  hearing  or  the  velum  palati. 

"  {c)  If,  finally,  the  nerve  is   diseased  below  the   giving  off  of  the 
chorda  in  the   Fallopian   canal,   we  only  find  paralysis  in  the  distri- 
bution  of  the  posterior   auricular   branch,  without   any  trouble  with  ' 
taste,  hearing,  the  condition  of  the  velum   palati,  or  the  secretion  of 
saliva." 

When  it  has  been  determined  that  the  nerve-affection  is  extra- 
cranial and  due  to  exposure,  an  electrical  examination  of  the  mus- 
cles should  be  made  before  expressing  an  opinion  on  the  probable 
duration  of  the  affection.  The  following  are  the  chief  points  to  guide 
us  : 

"  I.  If  W'e  find  no  changes  either  in  faradic  or  in  galvanic  excita- 
bility, the  prognosis  is  favorable ;  recovery  in  from  seven  to  twenty 
days  (light  form). 

"  2.  If  we  find  the  faradic  and  galvanic  excitability  of  the  nerve 
diminished,  but  not  lost,  the  galvanic  excitability  of  the  muscles, 
however,  increased,  and  the  usual  formula  of  contraction  changed 
(A.  C.  C.  >  C.  C.  C),  then  the  prognosis  is  relatively  favorable  ;  recovery 
in  from  four  to  six  weeks  (intermediate  form  of  Erb). 

"  3.  If  the  reaction  of  degeneration  be  found — /.  c.  if  the  faradic  and 
galvanic  excitability  of  the  nerve  and  the  faradic  excitability  of  the 
muscles  be  lost,  while  there  is  an  increase  in  the  galvanic  excitability 
of  the  muscles  associated  with  qualitative  changes  and  changes  in  the 
mechanical  excitability — then  the  prognosis  is  relatively  unfavorable, 
and  for  recovery  two,  four,  six,  eight,  even  twelve,  months  may  be 
required  (grave  form).  These  are  those  bad  cases  in  which  secondary 
contractures  and  spasmodic  twitchings  of  the  muscles  also  appear, 
which,  according  to  Hitzig's  opinion,  are  to  be  referred  to  an  obscure 
abnormal  irritation  of  the  medulla  oblongata.  It  is  well  to  know  that  as 
convalescence  begins  voluntarily  motion  may  return  long  before  the 
electrical  excitability,  so  that  often  the  patient  is  able  to  perform  some 
slight  voluntary  movements  before  faradic  stimulation  provokes  the 
least  contraction." ' 

Treatment. — In  the  majority  of  cases  of  facial  paralysis  brought  on 
by  exposure  to  cold  no  treatment  is  needed,  as  the  nerve  returns  to  a 

1  Op.  cit.,  p.  90. 


552 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


healtliy  cvondition  and  the  paralysis  passes  off  in  due  time.     When  the 

disease  is  more  protracted,  electricity 
affords  the  best  results  and  should 
be  persevered  in.  Both  galvanic  and 
faradic  currents  are  valuable.  The 
motor  points  from  which  the  prin- 
cipal facial  muscles  can  be  stimulated 
are  shown  in  Fig.  244. 

2.  The  Pneumog-astric.  —  The 
pneumogastric  nerve  has  been  ligated 
in  operations  for  tying  the  carotid 
artery,  and  its  recurrent  laryngeal 
branch  has  been  divided  in  removing 
goiters.  The  effects  of  this  accident 
are  hoarseness  and  change  in  the  voice 
from  paralysis  of  the  vocal  cord  of 
the  injured  side.  Should  both  re- 
current laryngeal  nerves  be  severed, 
suffocation  would  result  from  paral- 
ysis of  the  larynx,  and  an  immediate 
tracheotomy  is  necessary  to  save  the 

patient's  life.     Division  or  ligation  of  one  pneumogastric  is  not  a  very 

serious  matter,  as  it  only  produces  hoarseness. 


Fig.  244. — Some  of  the  so-called  "  motor- 
points  "  on  the  face  and  neck  (after  Hirt). 


Fig.  245. — Right-sided  serratus  paral- 
ysis (after  Eichhorst). 


Fig.  246. — The  same  case  with  the  arms  raised 
(after  Eichhorst). 


3.  The  posterior  thoracic  arises  from  the  fifth  and  sixth  cervical 
nerves,  and  supplies  the  serratus  magnus  muscle.     A  lesion  of  this 


DISEASES  AND   INJURIES   OF  NERVES. 


553 


nerve,  producing  paralysis  of  the  muscle,  is  sometimes  observed  in 
persons  who  carry  hea\y  loads  on  the  shoulder,  or  in  certain  occu- 
pations, such  as  mowing,  shoemaking,  and  tailoring,  which  produce 
over-exertion  of  the  serratus  ;  sometimes  the  paralysis  appears  to  follow 
an  exposure  to  cold. 

Syniptouis. — When  the  arm  is  at  rest  the  scapula  appears  elevated, 
and  its  lower  angle  is  abnormally  near  the  v^ertebral  spines  (Fig.  245), 
this  position  being  due  to  the  action  of  the  rhomboids,  the  levator 
angulae  scapulae,  and  trapezius,  which  are  the  muscles  antagonizing  the 
serratus.  When  the  arm  is  raised  in  front  of  the  chest  the  posterior 
border  of  the  scapula  is  tilted  outward,  so  that  the  inner  surface  of  the 
bone  can  be  felt  (Fig.  246).  This  form  of  paralysis  is  extremely  ob- 
stinate, and  may  last  for  weeks,  months,  or  even  years,  in  spite  of  all 
treatment. 

4.  The  Musculo-spiral  Nerve. — Paralysis  of  this  nerve  produces 
the  very  characteristic  deformit)'  known  as  wrist-drop  (Fig.  247).  Its 
most  common  cause  is  a  fracture  of 

the  humerus,  which  involves  the  mus- 
culo-spiral groove.  The  extensor 
muscles  become  paralyzed  and  the 
patient  is  unable  to  rai.se  his  hand 
into  line  with  his  outstretched  arm. 
When  the  injury  is  above  the  branch 
supplying  the  supinator  longus, 
flexion  and  supination  are  impaired, 
but  not  entirely  lost,  as  the  biceps 
and  supinator  brevis  are  still  intact. 

5.  The  Radial  Nerve. — This  nerve 
is  sometimes  divided  just  above  the 
wrist  on  the  back  of  the  forearm.  It 
produces  no  paralysis,  as  it  supplies 
no  muscles :  it  is  marked  by  loss  of 
sensation  in  the  skin  over  the  meta- 
carpal bones  and  first  phalanges  of  the  thumb  and  fore  finger. 

6.  The  Median  Nerve. — This  nerve  may  be  divided  in  any  part  of 
the  forearm,  but  especially  above  the  wrist.  If  the  injury  be  above  the 
elbow,  all  the  flexors  and  pronators  of  the  arm  will  be  paralyzed,  except 
the  flexor  carpi  ulnaris  and  the  ulnar  half  of  the  flexor  profundus.  The 
muscles  of  the  thumb,  except  the  adductor  and  half  of  the  flexor  brevis 
pollicis,  will  also  be  affected ;  flexion  of  the  wrist  on  the  radial  side  will 
be  lost,  and  the  thumb  cannot  be  opposed  to  the  other  fingers.  The 
changes  in  sensation  are  as  follows :  On  the  palmar  surface  anesthesia 
or  paresthesia  will  extend  over  half  of  the  palm  and  the  palmar  surface 
of  the  thumb,  index,  and  middle  finger,  the  radial  side  of  the  ring  finger 
except  a  small  part  at  its  tip.  On  the  posterior  surface  anesthesia 
affects  the  whole  of  the  fore  and  middle  fingers  and  the  radial  side  of 
the  ring  finger  (Figs.  248,  249). 

7.  The  Ulnar  Nerve. — Paralysis  of  this  nerve  occurs  in  certain 
occupations  in  which  the  workmen  are  obliged  to  press  the  elbow 
firmly  upon  a  hard  surface  or  to  use  the  ulnar  side  of  the  hand  in 
striking   instruments.      It  may   also   suffer  injurj^   or    division    at   the 


Fig.  247. — Paralysis  of  musculo-spiral 
nerve  after  fracture  of  the  humerus  ("  wrist- 
drop ");  but  when  fingers  have  been  flexed 
into  palm,  a,  they  can  be  extended,  b,  at 
first  inter-phalangeal  joints  by  lumbricals 
and  interossei,  which  are  supplied  by  the 
ulnar  and  median  nerves  (Erichsen). 


554 


SURGICAL   DIAGNOSIS  AXD    TREATMENT. 


elbow,  the  upper  arm,  or,  most  frequently,  just  above  the  wrist.     Paral- 
ysis of  both  motion  and  sensation  follows. 

JSIotor  Paralysis. — In  the  forearm  the  flexor  carpi  ulnaris  and  the 
inner  half  of  the  flexor  profundus   are  paralyzed.     In  the   hand  the 


Ml 


/ 


>f  ^ 


Fig.  248. — Section  of  median  nerve  : 
regions  of  anesthesia  and  dysesthesia  on 
dorsal  surface  of  hand  (Bowlby). 


Fk;.  249. — Section  of  median  nerve : 
areas  of  anesthesia  (heavy  shading)  and 
of  dysesthesia  (hght  shading)  on  palmar 
surface  of  hand  (Bowlby). 


whole  group  of  muscles  forming  the  hypothenar  eminence,  the  two 
ulnar  lumbrical  muscles,  the  adductor  pollicis,  half  of  the  flexor  brevis 
pollicis,  and  all  of  the  interossei  are  affected.  The  muscles  soon  be- 
come  atrophied ;    the  interosseal    spaces   on    the    back    of   the    hand 


Fig.  250. — Paralysis  of  ulnar  nerve  from  wound  at  A  ;  contracture  of  common  extensor  with 
posterior  luxation  of  first  phalanges  ;  B,  head  of  metacarpal  bone  (Duchenne). 

become  hollowed;  and,  if  wasting  is  confined  to  the  interossei  and 
lumbricales,  their  antagonists,  the  extensor  communis  digitorum  and 
the  flexor  digitorum,  produce  that  disagreeable  deformity  known  as 
claw-hand  or  main  en  griffe.     It  consists  in  a  dorsal  flexion  of  the  first 


DISEASES  AND   INJURIES   OF  NERVES. 


555 


phalanges    and   a  complete   palmar  flexion   of  the   second   and   third 
(Fig.  250). 

Sensation. — Allowing  for  changes  in  the  distribution  of  the  nerve  in 
different  individuals,  sensation  will  be  lost  over  the  ulnar  portion  of  the 
skin  of  the  hand,  the  whole  of  the  little  finger,  and  the  ulnar  half  of 
the  ring  finger,  except  a  small  point  at  the  tip  which  is  supplied  by  the 
median  nerve  (Fig.  251). 


Fig.  251. — Loss  of  sensation  on  anterior  and  posterior  surfaces  of  hand  after  division  of  the 

ulnar  nerve  (Bowlby). 


8.  The  Sciatic. — This  nerve  is  seldom  injured  except  in  gunshot 
wounds.  When  the  external  popliteal  branch  is  divided,  as  sometimes 
happens  in  tenotomy  of  the  biceps,  the  muscles  of  the  anterior  surface 
of  the  leg  are  paralyzed,  so  that  the  foot  drags  in  walking.  It  can  be 
neither  flexed,  abducted,  nor  adducted.  The  toes  are  constantly  trip- 
ping over  prominences  on  the  floor,  and  to  overcome  this  the  patient 
forms  the  habit  of  rai.sing  the  thigh  higher  than  usual.  In  the  course 
of  time  the  contraction  of  the  calf-muscles  are  apt  to  produce  talipes 
equinus  or  talipes  equino-varus.  This  nerve  may  be  injured  by  pressure 
where  constant  kneeling  is  required,  as  in  asphalt-paving. 

The  internal  popliteal  branch  supplies  the  muscles  of  the  back  of 
the  leg  and  the  sole  of  the  foot.  Injury  to  this  nerve  interferes  with 
plantar  flexion  of  the  foot  and  with  flexion  and  lateral  motion  of  the 
toes.  The  patient  is  unable  to  stand  on  tiptoe.  If  the  interossei  mus- 
cles are  paralyzed,  the  first  phalanx  of  each  toe  is  dorsally  flexed, 
w'hile  the  second  and  third  are  in  plantar  flexion,  and  a  deformity  is 
produced  similar  to  the  claw-hand  already  described. 


55^  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

CHAPTER  XI. 
INJURIES  AND  DISEASES  OF  THE  RESPIRATORY  SYSTEH. 

I.  THE  NOSE. 

Bxternal  injuries  of  the  nose  are  of  importance  in  the  surgery 
of  the  respiratory  tract  only  as  they  affect  the  nasal  orifices.  They 
may  be  the  result  of  falls,  blows,  gunshot  wounds,  burns,  and  scalds, 
and  if  deep  and  extensive  tend  to  bring  about,  by  the  contraction  of  the 
resulting  cicatricial  tissues,  the  partial  or  complete  closure  of  one  or 
both  nasal  orifices. 

Treatment  is  preventive  rather  than  curative.  Occlusion  should  be 
prevented  and  the  caliber  of  the  nostril  maintained  by  the  insertion  of 
sponges,  bougies,  etc.  Repeated  dilatations  may  be  necessary,  and 
also  incision  of  the  cicatricial  tissue  at  various  points. 

Elephantiasis  occurs  very  rarely — only  in  middle  and  old  age, 
attaining  at  times  excessive  proportions. 

The  treatment  is  excision.  It  has  little  or  no  effect  upon  the 
respiratory  tract,  being  unlike  in  that  respect  the  much  graver  affection 
which  we  shall  next  consider — viz  : 

Rhino-scleroma. — This  disease,  starting  at  the  edge  of  the  nostril, 
may  invade  not  only  the  external  parts  of  the  nose,  but  also  the  upper 
lip,  septum,  and  nasal  passages,  and  even  the  mouth,  larynx,  and 
pharynx.  It  is  due  to  the  action  of  a  bacillus  which  is  capable  of 
inoculation.  It  is  really  a  tumor  of  a  densely  hard,  smooth  sort, 
raised  somewhat  above  the  cutaneous  or  mucous  surface,  and  may 
appear  as  one  patch  which  enlarges  slowly,  or  as  several  with  slight 
separations  between,  giving  them  a  lobulated  appearance.  There  is 
little  if  any  ulceration  or  pain.  It  may  not  differ  markedly  from  the 
skin  in  color,  or  it  may  be  somewhat  darker  of  a  grayish-pink  color. 
The  growth,  whether  within  or  without,  gives  excessive  deformity  to 
the  nose,  and  hence  tends  to  occlude  the  nasal  passages. 

It  differs  from  other  tumors  and  malignant  growths  by  its  great 
hardness,  and  can  be  differentiated  from  syphilis  by  its  slow  growth 
and  resistance  to  specific  treatment.  Treatment  is  of  little  avail.  Dou- 
trelepont  reports  a  case  which  was  cured  by  repeated  inunctions  of 
lanolin  containing  i  per  cent,  of  corrosive  sublimate. 

If  the  nasal  passages  are  obstructed,  portions  of  rhino-scleroma 
therein  can  be  removed  by  excision  or  caustics,  and  tracheotomy  must 
be  performed  if  it  reach  as  far  as  the  larynx.  Operations  in  the  nasal 
passages  must  be  frequently  repeated,  for  the  growth  recurs  after 
removal. 

Bxtemal  tumors  of  the  nose  may  be  either  benign  or  malignant, 
epithelioma  being  a  common  type  of  the  latter  class.  Lupus  is  also 
common.  These  diseases  present  no  characteristics  differing  from  those 
that  they  manifest  in  other  parts  of  the  body,  and  their  treatment  is  the 
same  as  elsewhere.  They  have  no  bearing  upon  the  respiratory  tract, 
except  when  by  the  contraction  of  cicatricial  tissue  they  cause  obstruc- 


INJURIES  AND  DISEASES   OF   THE   RESPIRATORY  SYSTEM.    557 

tion  to  respiration.  In  that  case  the  treatment  is  the  same  as  for 
external  injuries. 

Internal  Injuries. — The  internal  parts  of  the  nose  may  be  impli- 
cated in  traumatism  of  the  soft  parts  of  the  face,  or  internal  injuries  may- 
be due  to  the  entrance  of  foreign  bodies  through  the  anterior  nares,  occa- 
sionally through  the  posterior  nares.  Through  the  integument  various 
substances  may  be  introduced  as  the  result  of  an  accident,  as  pieces  of 
glass,  splinters,  fragments  of  weapons,  bullets,  shot,  etc.  Through  the 
posterior  nares  an  act  of  vomiting  may  force  foreign  bodies  into  the  nose. 
Through  the  anterior  nares  various  articles,  as  buttons,  beads,  peas, 
beans,  bits  of  wood,  etc.,  are  often  pushed  by  children  and  insane  people. 

Symptoms. — If  these  foreign  bodies  are  rough  and  jagged,  an  acute 
rhinitis  is  set  up.  If  they  absorb  moisture  and  swell,  great  discomfort 
and  distress  from  pressure  and  pain  may  result.  If  they  are  smooth 
and  hard,  no  immediate  discomfort  may  be  felt.  In  addition  to  rhinitis, 
more  remote  symptoms  may  manifest  themselves,  as  pain,  headache, 
facial  neuralgia,  and  finally  a  fetid  catarrh.  When  the  latter  condition 
exists,  a  thorough  washing  of  the  nasal  cavity  is  necessary  more  accu- 
rately to  determine  the  nature  of  the  offending  substance,  and  par- 
ticularly if  no  history  of  a  foreign  body  in  the  nasal  passage  can  be 
elicited.  If  the  patient  can  furnish  a  history  of  a  foreign  body,  the  case 
is  comparatively  easy. 

Necrosed  bone  in  the  nasal  cavity  may  produce  a  like  train  of  symp- 
toms, though  probably  in  that  case  others  of  a  constitutional  sort 
would  afford  ground  for  a  differential  diagnosis. 

In  any  event,  the  existence  of  a  profuse  nasal  discharge,  giving 
evidence,  as  it  does,  of  intense  irritation,  would  lead  the  surgeon  to 
institute  a  thorough  examination  of  the  nasal  cavity  and  thus  bring  to 
light  the  foreign  body. 

Treatment. — The  foreign  body  must  be  removed.  Local  anesthetics 
may  be  sufficient,  but  in  the  case  of  children,  with  whom  the  greater 
number  of  such  accidents  occur,  ease,  certainty,  and  rapidity  of  ope- 
ration are  best  secured  by  completely  anesthetizing  the  patient.  Then 
a  small  pair  of  forceps,  especially  one  consisting  of  separate  blades  that 
may  be  carefully  adjusted,  is  usually  sufficient  for  its  removal.  A 
snare,  a  hook,  a  probe,  a  curved  bougie,  a  loop  of  wire,  or  other  con- 
trivance suited  to  the  nature,  size,  and  situation  of  the  object  and  the 
ingenuity  of  the  operator,  will  each  at  times  serve  the  purpose.  Gen- 
erally the  foreign  body  can  be  best  reached  from  the  anterior  nares. 
Sometimes,  however,  all  attempts  in  this  direction  are  unavailing, 
serving  only  to  push  it  farther  away.  Then  other  methods  of  pro- 
cedure are  open  to  the  surgeon — either  that  of  pushing  it  backward 
through,  or  of  withdrawing  it  from,  the  posterior  nares  by  some  suit- 
able instrument,  or  of  pushing  it  forward  by  a  curved,  slender,  flexible 
instrument  thrust  up  behind  the  velum.  If  you  push  it  backward,  be 
careful  that  it  does  not  enter  the  larynx. 

If  the  foreign  body  is  not  firmly  impacted,  some  simple  method  may 
effect  its  dislodgement.  Sneezing  may  loosen  it.  The  action  of  an 
emetic  when  the  mouth  is  closed  has  been  known  to  force  it  forward. 
A  thorough  douche  or  strong  injection  through  the  nostril  or  through 
the  posterior  nares  may  drive  it  forward.     Sometimes  by  the  softening 


558  SCKGICAL    DIAGXOSIS  AND    TREATMENT. 

of  the  surrounding  parts  from  ulceration  its  removal  is  in  time  effected 
without  instrumental  interference. 

If  the  irritation  which  it  produces  is  \Q.ry  intense,  and  none  of  the 
methods  mentioned  effect  its  remo\al.  it  ma)'  be  necessarj'  to  resort  to 
an  operation  the  character  of  which  will  be  determined  by  the  location 
and  size  of  the  foreign  bod}-.  The  ala  of  the  affected  nostril  may  be 
dissected  away  from  the  face  and  lifted  up,  or  there  may  be  a  median 
incision,  or  the  whole  nose  ma)'  be  raised  after  an  incision  through  the 
margin  of  the  upper  lip. 

Parasites  within  the  nasal  cavities  constitute  a  species  of  foreign 
bodies  fortunately  less  common  in  temperate  than  in  tropical  climates. 
Ascarides  lumbricoides  may  find  entrance  through  the  posterior  nares, 
either  during  the  act  of  vomiting  or  b)'  creeping  up  through  the  ali- 
mentar)'  tract.  The  Lucilia  hominivora  is  a  common  insect  of  the  class 
of  ^luscids  which  deposits  its  eggs  even  in  healthy  noses.  A  fetid 
catarrh  b)'  its  odor  attracts  flies,  and  they  lay  their  eggs  within  the 
nostrils  while  the  person  is  sleeping.  The  larvje  develop  rapidly, 
favored  by  the  warmth  and  moisture.  Centipedes,  earwigs,  leeches 
hav^e  all  been  demonstrated  within  the  nasal  cavities. 

The  mucous  membrane  is  first  intensel)^  hyperemic  from  the  pres- 
ence of  such  intruders,  then  it  ulcerates,  and  is  finally  destroyed,  its 
destruction  being  followed  by  necrosis  of  bone  and  cartilage  even  to  the 
point  where  meningitis  is  set  up. 

Symptoms  are,  first,  itching,  then  a  sense  of  fulness  and  discomfort, 
soon  followed  by  headache  and  a  severe  throbbing,  and  often  agonizing 
pain.     Delirium,  coma,  and  death  may  rapidly  ensue. 

The  nose,  throat,  face,  palate,  and  eyes  are  swollen  and  distorted, 
and  blood)-  and  fetid  discharges  occur ;  abscesses  form  through  which 
maggots  are  discharged. 

Diagnosis  is  clear  upon  demonstration  of  the  parasites. 

Treatment. — ]\Iorphin  may  be  used  to  relieve  the  intense  pain. 
Calomel  by  insufflation,  and  injections  of  turpentine,  alcohol,  and 
tobacco,  have  been  found  useful.  Chloroform,  either  diluted  or  of  full 
strength,  is  used  as  a  wash  in  the  nasal  passages.  Because  of  the 
violent  irritation  which  this  drug  produces  upon  mucous  membranes, 
it  is  best  to  produce  local  anesthesia  by  cocain  before  using  a  douche 
of  full  strength.  Disinfectant  washes  should  follow  the  use  of  chloro- 
form. If  the  parasites  make  their  way  into  any  of  the  sinuses,  an 
operation  will  be  necessar)*. 

Rhinoliths  are  nasal  calculi,  and  they  differ  from  calculi  formed  in 
other  parts  of  the  body  only  in  so  far  as  they  are  modified  by  location. 
The  nucleus  is  a  particle  of  solid  foreign  matter  lodged  in  the  nasal 
passage.  It  may  be  something  which  finds  its  way  into  the  nostril 
from  without,  or  it  may  be  a  bit  of  inspissated  mucus  or  a  pathological 
product  which  has  been  retained  within  the  cavity.  Successive  strata 
of  calcareous  matter  derived  from  the  alkaline  salts  of  the  secretions 
and  blood  are  deposited  around  it  until  a  calculus  is  formed,  its  size 
depending  upon  the  shape  and  dimensions  of  the  space  in  which  it 
originates.  Rhinoliths  may  be  so  small  as  not  to  be  noticed,  or  they 
may  be  so  large  as  completely  to  occlude  the  nasal  passages  and  weigh 
even  so  much  as  four  drams.     Thev  are  sometimes  ver\'  hard,  but  gen- 


INJURIES  AND  DISEASES   OF  THE   RESPIRATORY  SYSTEM.    559 

erally  are  quite  friable,  and  may  even  have  a  central  portion  not  so 
hard  as  the  outside.  They  are  generally  found  in  the  lower  portion 
of  the  nose,  either  next  to  the  septum  or  in  the  inferior  meatus,  though 
it  is  not  uncommon  for  them  to  lie  in  the  middle  meatus.  They  are 
usually  unilateral. 

The  commonest  symptoms  are  those  which  attend  partial  or  com- 
plete occlusion  of  the  nasal  passage,  although,  since  the  process  of 
formation  of  a  rhinolith  is  gradual,  the  symptoms  assert  themselves 
more  slowly  than  in  other  forms  of  occlusion.  Pain  is  constant, 
increasing  in  severity  and  in  the  extent  of  its  effects  with  the  growth 
of  the  calculus. 

If  the  concretion  is  large,  the  external  appearance  of  the  nose  may 
be  altered.  A  constant  symptom,  due  to  the  irritation,  is  a  nasal  dis- 
charge, muco-purulent  or  even  sanious.  Respiration  is  interfered  with, 
and  there  may  be  anemia. 

In  diagnosis  perhaps  the  commonest  mistake  is  to  regard  the  case  as 
one  of  ozena  or  a  common  fetid  catarrh,  judging  from  the  character  of 
the  discharge.  If  the  nose  is  seen  to  be  distorted  or  if  a  thorough  rhino- 
scopic  examination  is  made,  this  error  may  be  avoided.  Calcareous 
degeneration  of  the  mucous  membrane  is  to  be  differentiated  by  the 
fact  that  the  rhinolith  is  movable ;  osteomata,  by  their  being  immov- 
able and  by  their  greater  hardness.  Necrosis  of  bone  is  usually  less 
painful  locally,  attended  by  pronounced  constitutional  symptoms,  and 
inspection  gives  different  results.  Polypi  must  be  differentiated  by 
inspection.  Absence  of  the  characteristic  cachexia  and  their  slow 
growth  distinguish  them  from  cancer. 

The  treatment  is  removal,  differing  in  no  respects  from  that  of  other 
foreign  bodies. 

Polypi  occur  more  frequently  in  the  nasal  fossae  than  do  all  other 
growths  combined.  They  are  mucous  or  gelatinous  in  character,  and 
are  to  be  regarded  as  myxomata,  or,  if  slightly  fibrous,  as  fibro-myx- 
omata.  In  color  they  are  pale  pink,  grayish,  or  of  a  blue  tinge.  They 
are  soft,  pulpy,  semi-transparent,  and  easily  torn.  They  contain  few  if 
any  blood-vessels,  and  no  nerves.  A  simple  polypus  has  no  connection 
with  bone  or  cartilage,  but  grows  only  from  the  mucous  membrane, 
most  commonly  from  that  covering  the  middle  turbinated  bone ;  the 
next  most  common  site  is  the  superior  turbinated  bone  and  middle 
meatus,  and  rarest  of  all  the  septum.  They  are  covered  with  epithe- 
lium, that  of  the  mucous  membrane,  and  hence  are  often  ciliated.  They 
are  pendunculated,  and  really  have  but  one  original  place  of  attach- 
ment. If  they  have  or  appear  to  have  more,  it  is  because,  from  their 
large  size,  they  have  become  pressed  against  the  other  polypi,  the 
septum,  or  other  parts,  and  by  ulceration  and  healing  have  either 
formed  a  second  attachment  at  some  late  period  in  their  growth  or 
merely  seem  to  do  so — an  appearance  corrected  on  close  inspection. 
They  may  be  single,  either  large  or  small  in  size,  but  are  quite  as  apt 
to  be  multiple,  and  they  are  of  varied  form,  determined  by  the  space  in 
which  they  grow.  A  single  small  polypus  is  pyriform  in  shape,  the 
larger  portion  downward  because  of  the  weight  of  its  contents.  The 
constant  pushing  downward  and  forward  of  the  epithelium  of  the 
mucous  membrane  from  a  single  point  makes  a  narrow  stem-like  part 


560  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

near  the  place  of  orii^in.  Pressure  from  one  or  several  directions 
naturally  alters  its  shape  and  apijcarance. 

The  cause  o{  polypi  is  a  matter  of  much  doubt.  In  general  it  may 
be  said  that  the  immediate  cause  is  some  irritation  in  the  nasal  pas- 
sages, possibly  a  purulent  discharge  from  the  sinuses,  and  only  theories 
can  be  advanced  to  explain  why  an  irritant  should  produce  polypi  in 
one  case  and  not  in  another.  Something  additional  as  a  predisposing 
cause  must  exist.  ■ 

Some  authors,  Mackenzie  among  them,  find  a  predisposing  cause  in 
a  constitutional  condition,  in  an  inherited  dyscrasia,  as  tuberculosis, 
syphilis,  malarial  poison,  etc.  It  is  generally  believed  that  polypi 
occur  more  frequently  in  men  than  women.  They  are  exceedingly  rare 
in  children.  It  would  seem  that  the  irritation  arising  from  exposure  or 
overwork  is  an  exciting  cause. 

Symptoms. — During  the  very  earliest  stages  there  are  probably  no 
appreciable  symptoms.  As  a  polypus  develops,  an  indefinite  sense  of 
local  discomfort  is  present  and  the  amount  of  secretion  is  increased. 
When  of  sufficient  size  to  occlude  wholly  or  partially  the  nasal  passage, 
respiration  is  more  or  less  interfered  with,  especially  when  the  polypus 
is  swollen  from  damp  air.  At  times  breathing  is  audible,  almost  snoring. 
The  voice  gives  the  nasal  "  twang  "  heard  in  all  obstructions  of  the 
nasal  chambers. 

The  discharge  from  the  nostrils  becomes  more  irritating  and  offen- 
sive in  character,  and  may  even  be  mixed  with  blood,  or  frequent  and 
severe  attacks  of  epistaxis  may  be  the  strongest  indication  of  an  abnor- 
mal condition. 

Reflex  symptoms  are  common,  such  as  hemicrania,  facial  neuralgia, 
partial  or  complete  loss  of  hearing,  anosmia,  and  cough.  The  nose 
may  become  large  and  distorted,  and  the  polypi  may  press  backward 
into  the   naso-pharynx. 

Diagnosis  is  usually  unattended  with  difficulty  or  embarrassment,  at 
least  when  the  disease  has  advanced  beyond  the  first  stage.  Other 
pathological  conditions  of  the  nasal  cavities  are  so  unlike  this  that  they 
need  scarcely  be  considered  if  attention  be  given  to  the  distinctive  cha- 
racteristics of  polypi.  By  rhinoscopic  examination  they  are  seen  to 
depend  from  the  nasal  cavity,  and  are  easily  movable,  even  swaying  or 
flapping  with  a  slight  sound  at  times  under  the  impulse  of  a  current  of 
air.  If  this  sort  of  movement  is  not  present,  some  delicate  instrument 
in  the  hands  of  the  surgeon  easily  produces  motion  of  the  dependent 
pyriform  portion. 

Prognosis  as  to  life  is  favorable,  but  not  as  to  recurrence.  Since 
the  cause  of  their  occurrence  is  so  obscure,  it  is  difficult  to  predict 
that  polypi  will  not  return.  The  cause  may  still  exist  and  produce 
a  new  crop,  or  the  mass  may  not  be  wholly  removed,  and  still  con- 
tinue to  grow ;  or  if  a  large  mass  is  thoroughly  eradicated,  small  ones 
may  be  overlooked  and  grow  rapidly. 

Treatment. — Various  methods  of  removal  have  been  employed,  but 
a  surgical  operation  only  is  to  be  recommended,  simple  or  complex 
according  to  the  conditions  of  the  case  and  the  adaptation  and  inventive 
genius  of  the  surgeon. 

Avulsion  probably  stands  as  the  operation  most  generally  employed. 


INJURIES  AND  DISEASES   OF  THE   RESPIRATORY  SYSTEM.    56 1 

and  consists  in  removal  by  forceps,  rotary  motion  being  used  to  twist 
the  polyp  from  its  pedicle. 

The  forceps  should  be  light,  strong,  and  curved  to  keep  the  sur- 
geon's hand  from  obstructing  his  view.  The  nostril  is  dilated  with 
some  suitable  nasal  speculum  and  well  illumined.  The  mstrument  (one 
with  separate  blades  is  sometimes  an  advantage)  is  made  to  grasp  the 
base  of  the  polyp  as  firmly  as  possible,  and  by  a  steady  twisting  motion 
sever  the  growth  from  its  connection.  Bleeding  is  generally  slight,  and 
depends  upon  the  position  of  the  growth.  The  surgeon  ought  to  see 
or  feel  the  pedicle  in  order  to  secure  rapid  and  accurate  adjustment  of 
the  forceps.  If  this  is  impossible,  as  when  the  growth  is  large  or  far 
back  or  not  veiy  friable,  he  may  be  obliged  to  take  it  away  a  little  at  a 
time.  If  it  is  well  formed  and  of  firm  consistency,  it  may  be  partially 
drawn  out  of  the  nostril  and  its  pedicle  cut  with  knife  or  scissors. 
Stoker's  forceps  were  invented  especially  for  the  removal  of  nasal 
polypi,  and  are  well  spoken  of 

Avulsion  by  the  ecraseur  or  wire  snare  is  a  convenient  method  of 
treatment.  The  loop  of  the  instrument  is  first  adjusted  about  the 
pedicle  and  then  tightened  until  it  cuts  through.  It  is  a  slower  process 
than  that  in  which  forceps  are  used,  but  the  hemorrhage  is  probably 
less.  Jarvis's  snare  (Fig.  252),  invented  for  this  particular  kind  of 
surgery,  is  the  best  now  in  use. 


Fig.  252. — Jarvis's  wire  snare-ecraseur. 

The  galvano-cautery  presents  also  a  possible  method  of  eradication. 
Objections  to  it  are  the  great  pain,  the  difficulty  of  adjusting  it  in  many 
cases,  and  the  fact  that  it  makes  no  traction,  and  hence  may  leave  a 
fragment    i)i  situ  and  make  repetition  necessary. 

With  any  of  these  methods  cocain  is  locally  applied,  disinfectant 
washes  should  be  used,  and  if  hyperemia  and  inflammation  follow  the 
operation,  astringent  applications  are  indicated.  If  the  patient  decline 
the  operation,  attempts  at  removal  may  be  made,  as  they  were  in  former 
years,  by  the  action  of  caustics  or  astringents  applied  or  injected. 

For  applications  are  recommended  tannin  (by  insufflation),  iodin, 
perchlorid  of  iron,  nitrate  of  silver,  zinc  chlorid,  gallic  acid,  etc. 

The  drugs  employed  for  injection  are  carbolic  acid,  glacial  acetic 
acid,  chromic  acid,  or  some  strong  astringent,  as  Lugol's  or  Monsell's 
solution. 

Fibro-myomata  and  Fibromata. — Between  the  simple  gelatinoid 
polypus  and  the  true  fibroma  may  be  found  mixed  tumors  of  all  grades, 
from  those  containing  the  slightest  trace  of  fibrous  material  to  those  dif- 
ficult to  differentiate  from  a  true  fibroid  ;  the  gravity  of  the  case  varies 
in  proportion  to  the  amount  of  fibrous  substance,  because  that  is  very 
vascular,  and  the  chief  danger  of  removal  lies  in  the  hemorrhage.  Pure 
fibromata  within  the  nose  are  very  rare. 

A  naso-pharyngeal  fibro-myxoma  is  recognized  by  its  occupying  the 
position  indicated  by  its  name,  and  arises  generally  from  the  basilar 
36 


562  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

process  of  the  occipital  bone  and  from  bony  structures  in  its  immediate 
vicinity.     It  grows  rapidly  and  to  a  large  size. 

Other  nasal  fibrous  polypi  arise  from  any  portion  of  the  walls  of  the 
nasal  fossa;,  generally  farther  back  than  is  the  case  with  mucous  polypi, 
and  their  favorite  site  is  the  superior  turbinated  bone,  the  roof  of  the 
nose,  and  rarely  the  vomer  or  the  foramen  lacerum  anterius  (Roberts). 
They  may  originate  in  some  of  the  sinuses  and  extend  into  the  nose, 
protruding  at  the  anterior  nares,  and  may  have  several  places  of  attach- 
ment as  the  result  of  as  many  points  of  ulceration.  In  pathological 
structure  they  differ  in  no  way  from  similar  growths  in  other  parts  of 
the  body. 

Fibrous  polypi  often  attain  enormous  proportions,  distorting  hideously 
the  nose  and  face,  often  producing  the  so-called  "  frog-face  "  and  even 
exophthalmos.  By  pressure  also  they  destroy  adjacent  parts,  thereby 
endangering  the  brain,  producing  convulsions,  coma,  and  death. 

The  syviptovis  are  those  of  foreign  bodies  in  the  nasal  passages  if 
we  emphasize  the  constant  epistaxis,  the  greater  severity  of  all  symp- 
toms, and  the  magnitude  of  the  displacement  and  distortion. 

The  diagnosis  from  other  foreign  bodies  and  growths  heretofore 
described  is  plain  if  we  keep  in  mind  the  distinctive  characteristics  of 
the  latter.  From  malignant  growths,  and  even  from  those  of  syphilitic 
origin,  the  diagnosis  at  times  presents  difficulties.  Microscopic  exam- 
ination of  a  detached  portion  in  the  former  case  and  specific  treatment 
in  the  latter  will  clear  the  diagnosis. 

These  growths  occur  more  frequently  in  males  than  in  females,  and 
their  cause  is  entirely  unknown. 

Prognosis  as  to  life  must  be  guardedly  given,  for  they  tend  to 
become  malignant.  On  removal  fatal  hemorrhage  may  supervene, 
and  finally  they  may  recur  with  new  complications.  Attempts  at 
removal  may  betray  a  connection  with  the  dura  mater  or  reveal  a 
hernia  of  the  brain  through  the  distended  cribriform  plate  of  the  eth- 
moid bone.  Cases  have  been  recorded  of  the  spontaneous  detachment 
and  expulsion  of  such  growths,  but  the  proportion  of  such  cures  is  too 
small  to  modify  the  general  law  that  surgical  interference  affords  the 
only  true  remedy. 

Treatment. — Complete  extirpation  is  the  only  proper  course,  and  few 
conditions  present  greater  obstacles  to  the  surgeon,  both  from  the  dif- 
ficulty of  reaching  them  and  from  the  liability  to  hemorrhage.  When 
they  are  found  in  the  anterior  nasal  chambers  the  same  methods  are 
available  as  in  the  case  of  the  gelatinoid  polyp. 

When,  outgrowing  the  nasal,  it  has  invaded  contiguous  cavities  and 
displaced  or  destroyed  neighboring  structures,  or  when,  arising  more  or 
less  remote  from  the  nasal  chambers,  it  has  invaded  and  distorted  them, 
the  question  of  removal  becomes  a  veiy  grave  one. 

Avulsion,  the  ecraseur,  caustics,  electrolysis,  the  ligature  either 
simple  or  the  galvano-caustic  ligature,  have  each  their  advocates,  and 
with  each  successful  operations  have  been  performed.  Preponderance 
of  modern  surgical  opinion  is  decidedly  in  favor  of  the  use  of  the  knife 
in  radical  operations,  these  older  methods  being  merely  accessory, 
choice  as  to  one  or  the  other  depending  upon  the  location,  size,  place 
of  origin,  extension  into  other  cavities,  involvement  of  other  structures. 


INJURIES  AND  DISEASES   OF   THE   RESPIRATORY  SYSTEM.    563 

and  as  to  whether  eradication  with  the  knife  alone  is  possible  or  whether 
complete  ablation  must  be  accomplished  by  some  additional  means. 

Operations  through  the  mouth  produce  no  deformity,  but  afford  too 
little  space  for  checking  the  hemorrhage  and  for  removing  the  growth 
if  it  be  of  large  dimensions.  The  nose  may  be  divided  or  lifted  or  the 
nasal  bones  may  be  resected,  either  alone  or  with  the  superior  maxillary 
bone ;  the  upper  jaw  may  be  wholly  or  partially  excised. 

Partial  excision  of  the  superior  maxillary  bone  is  the  common  ope- 
ration, giving  the  best  exposure  of  the  polypus,  the  largest  space  for 
operating  and  removing  the  growth  and  for  managing  hemorrhage,  as 
well  as  the  least  disfigurement  after  repair  takes  place. 

Papillomata  are  found  at  the  junction  of  the  skin  and  mucous 
membrane,  being  somewhat  soft  in  the  latter  position,  hard  in  the 
former.  Caustics  easily  effect  their  removal,  though  a  loop  of  wire, 
the  knife,  or  scissors  may  be  used. 

Adenomata  and  cysts  are  to  be  regarded  as  modifications  of 
mucous  polypi,  with  similar  symptoms  and  treatment,  though  the 
former  may  take  on  the  characteristics  of  carcinoma,  and  the  latter 
do  not  tend  to  recur  when  once  their  contents  are  evacuated. 

Hnchondromata  are  usually  found  on  the  anterior  portion  of  the 
septum,  and  are  to  be  regarded  as  outgrowths  or  thickenings  of  its 
cartilaginous  portion.  Careful  slicing  with  the  knife  easily  effects  their 
remo\'al. 

Osseous  growths  present  two  or  three  varieties.  They  occur 
farther  back  in  the  nasal  fossa  than  do  enchondromata,  and  spring 
from  the  bony  part  of  the  septum,  from  the  vomer,  from  the  palatine 
plate  of  the  superior  maxillar>^  or  from  the  floor  or  roof  of  the  nose. 
Exostoses  differ  in  no  way  from  those  found  in  other  parts  of  the  body. 
Other  growths,  osteomata  proper,  are  either  of  a  density  like  ivor>'  or 
they  are  composed  of  cancellous  bony  tissue  with  frequent  admixture 
of  cartilaginous  tissue,  or  of  a  mucus-like  substance  within  relatively 
large  cavities. 

Treatment. — When  the  growth  is  very  hard  it  can  be  sawn  or 
chiselled  away  or  removed  with  the  dental  engine,  or,  if  the  pedicle 
be  slight,  with  scissors,  wire  loop,  forceps,  or  knife.  Only  occasionally 
it  is  an  opening  larger  than  that  afforded  by  the  natural  cavity  required, 
and  then  usually  some  minor  osteoplastic  operation  is  employed.  Oste- 
omata of  cancellous  tissue  are  friable,  and  may  be  removed  piecemeal 
without  enlarging  the  nasal  opening,  and  generally  do  not  recur. 

Angeiomata  are  rare,  with  epistaxis  as  the  chief,  persistent,  and 
even  dangerous  symptom. 

Malignant  growths  are  not  infrequently  found  in  the  nasal 
passages,  sarcomata  more  frequently  than  carcinomata.  Either  may 
be  primary,  but  most  of  the  benign  varieties  of  tumors  already  de- 
scribed show  a  tendency  to  malignant  degeneration,  particularly  the 
fibrous  polypi,  the  adenomata,  fibromata,  papillomata,  and  even  the 
simple  mucous  polypi.  Osteomata  are  often  of  mixed  type — osteo-sar- 
comata.  They  originate  from  all  parts  of  the  nasal  cavities,  sarcomata 
preferring  the  septum. 

Of  the  two,  sarcoma  is  the  more  frequent,  and  quickly  declares 
itself,  even  to    external   inspection,  by  its   red,   lobulated   appearance, 


564  SCRGICAL   DIAGNOSIS  AND    TREATMENT. 

its  extreme  vascularity,  and  its  being  sessile.  It  spreads  rapidly  to 
the  contiguous  or  connected  cavities,  often  invading  the  throat,  mouth, 
orbit,  or  cranium.  Its  ulceration  gives  rise  to  frequent  and  alarming 
epistaxis. 

Carcinoma  begins  more  insidiously  as  an  insignificant  growth, 
wart,  or  pimple.  The  local  symptoms  are  in  general  the  same  as 
those  of  benign  growths,  and  the  constitutional  symptoms  are  those 
which  distinguish  malignant  tumors  elsewhere.  If  they  are  secondary 
in  the  nose,  the  constitutional  symptoms  have,  very  likely,  existed  for 
a  considerable  time. 

Microscopical  examination  of  a  portion  finally  determines  the 
diagnosis. 

The  prognosis  is  most  unfavorable. 

In  treatment  extirpation  is  the  only  rule,  either  with  the  knife  or  the 
galvano-cautery.  However,  access  to  the  posterior  regions  is  so  dif- 
ficult, and  invasion  of  the  lymphatics  in  this  vicinity  so  certain,  that  the 
surgeon  can  rarely  be  sure  of  the  success  of  his  operation.  Not  only 
is  recurrence  the  rule,  but  imperfect  attempts  at  removal  stimulate  and 
accelerate  the  growth,  and  so  tend  to  shorten  rather  than  prolong  life. 

Kpistaxis. — Hemorrhage  from  the  nose,  though  in  the  majority  of 
cases  a  trifling  matter,  may  become  of  very  grave  import.  It  is  not  a 
disease,  but  a  symptom.  It  may  occur  spontaneously  without  dis- 
coverable cause  as  an  expression  of  personal  dyscrasia  or  idiosyncrasy. 
It  is  sometimes  a  symptom  of  local  pathological  conditions ;  frequently 
it  is  the  result  of  external  injuries,  blows,  falls,  etc.  It  may  be  the 
symptom  of  a  constitutional  disorder  either  recognized  or  unknown,  or 
it  may  be  congenital.  The  hemorrhage  is  either  active  or  passive — 
active  when  there  is  a  sudden  determination  of  blood  to  the  head ;  pas- 
sive when  the  cause  exists  for  a  considerable  time,  as  in  the  case  of 
acute  specific  diseases  and  in  subjects  of  the  hemorrhagic  diathesis. 

It  is  common  in  those  of  plethoric  habit,  either  children  or  adults, 
and  likewise  in  those  suffering  from  anemia.  Slight  erosions  of  the 
nasal  mucous  membrane,  deviation  of  the  septum,  growths  and  ulcers 
in  the  nose,  picking  at  the  nose,  inhalation  of  irritant  gases,  blows 
and  falls  upon  the  nose,  face,  or  head,  over-exertion,  passing  from  a 
dense  to  a  rare  atmosphere,  coughing,  sneezing,  blowing  the  nose,  ex- 
citement, mental  emotion,  are  all  mentioned  as  common  causes  of 
epistaxis. 

Various  acute  diseases  and  morbid  conditions  of  the  blood  predis- 
pose to  it,  as  scarlet  fev^er,  measles,  leukemia,  typhoid  fever,  and  the 
like.  Cardiac,  renal,  and  hepatic  diseases  may  lead  to  it ;  so  also,  occa- 
sionally, may  tuberculosis.  It  is  commonly  a  concomitant  of  hemo- 
philia, and  also  is  often  vicarious.  The  Schneiderian  membrane  is  very 
vascular,  and  its  vessels  have  comparatively  slight  support  from  sur- 
rounding tissues  ;  hence  it  has  a  greater  tendency  to  bleeding  than 
other  mucous  membranes. 

Symptoms. — The  blood  coming  from  the  nostril  is  of  course  the 
main  symptom  This  may  be  preceded  by  a  sense  of  fulness  or  dizzi- 
ness in  the  head,  headache,  tickling  in  the  nose  or  a  sensation  of 
warmth,  so  that  a  subject  prone  to  attacks  of  epistaxis  is  warned  of 
their  approach.     Usually  the  flow  of  blood  is  from  only  one  nostril. 


INJURIES  AND  DISEASES   OF  THE   RESPIRATORY  SYSTEM.    565 

though  when  it  is  a  constitutional  symptom  it  may  proceed  from  both. 
It  is  arterial  in  color,  and  coagulates  easily.  When  the  epistaxis  arises 
from  a  grave  constitutional  disorder  it  is,  of  course,  far  more  apt  to  be 
excessive  and  to  resist  treatment  than  when  the  cause  is  merely  within 
the  nose  itself,  and  especially  if  it  is  only  a  temporary  condition. 

There  is  usually  no  confusion  in  the  diagnosis.  If  the  ruptured 
capillaries  are  far  back  in  the  nares,  and  especially  if  the  hemorrhage 
occur  during  sleep,  the  blood  may  flow  backward  and  be  expectorated 
as  if  coming  from  the  lungs  or  stomach.  A  close  inspection  of  blood 
that  thus  makes  its  appearance,  if  there  is  no  previous  histor}^  pointing 
to  possible  hematemesis  or  hemoptysis,  will  make  the  case  clear.  In 
cases  where  the  origin  of  the  bleeding  is  in  the  sinuses  its  exact  loca- 
tion may  be  extremely  difficult.  Sometimes  when  the  flow  is  profuse, 
though  its  origin  is  in  only  one  nostril,  it  flows  from  both,  and  until  the 
flow  is  checked  it  may  not  be  possible  to  establish  the  fact  of  its 
unilateral  origin. 

Prognosis  is  grave  in  exact  proportion  to  the  gravity  of  the  cause 
and  to  the  depletion  of  the  system  before  the  patient  is  seen. 

Treatment. — Most  of  the  common  methods  of  preventing  "  nose- 
bleed "  are  known  to  the  laity,  such  as  pressing  the  ala  against  the 
septum,  the  application  of  ice  or  cold  water  to  the  bridge  of  the  nose  or 
back  of  the  neck,  dropping  a  cold  key  down  the  back,  raising  the  arm 
of  the  corresponding  side  above  the  head,  placing  a  wad  of  paper  lightly 
under  the  upper  lip,  pressing  the  finger  against  the  facial  arter}',  plugging 
the  anterior  nares,  the  use  of  hot  water  in  the  nose,  washing  the  face 
in  hot  water,  and  even  the  application  of  the  drugs  most  common  in 
domestic  use,  as  borax,  alum,  etc.  The  patient  should  remain  erect  or 
nearly  so  ;  he  should  not  bend  the  head  or  blow  the  nose.  If  the  sub- 
ject is  of  plethoric  habit  or  the  hemorrhage  arises  from  some  obstruc- 
tion to  the  circulation,  as  in  cardiac  disease,  or  is  vicarious,  moderate 
bleeding  is  beneficial  rather  than  harmful.  If  it  passes  the  bounds  of 
moderation  or  is  an  accompaniment  of  a  depressing  constitutional  dis- 
ease, and  if  the  simple  methods  above  mentioned  are  of  no  avail,  more 
vigorous  measures  should  be  undertaken  by  the  surgeon. 

In  many  cases  the  blood  comes  from  a  single  point,  and,  when  pos- 
sible, this  point  should  be  found,  wiped  with  a  piece  of  dry  cotton,  and 
touched  with  silver  nitrate,  chromic  acid,  or  the  galvanic  cautery. 

Astringents — nitrate  of  silver,  tannin,  perchlorid  of  iron,  antipyrin, 
etc. — either  as  sprays  or  applied  upon  cotton,  are  sometimes  of  service. 
Ergot,  internally,  is  usually  given  in  obstinate  cases.  Quinin  is  given 
if  malaria  is  seen  to  be  the  main  feature  in  the  case,  and  cases  rescued 
by  transfusion  have  been  reported. 

When  all  such  measures  prove  unavailing  plugging  is  resorted  to. 

Various  devices  have  been  invented  for  this  purpose,  among  them 
the  dilatable  air-bag  with  two  bulbs  an  inch  apart.  It  is  inflated  after 
having  been  placed  in  the  nares,  and  fits  all  parts  with  equal  pressure. 
It  is  easily  removed  after  allowing  the  air  to  escape.  So  suitable  an 
instrument  is,  however,  seldom  at  hand  at  the  critical  moment,  and  the 
surgeon  is  left  to  meet  the  situation  with  instruments  of  more  common 
use.  If  the  hemorrhage  is  believed  to  be  in  the  anterior  nares,  that 
may  be  plugged  either  with  iodoform  gauze  or  lint  as  tampons  pressed 


566  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

gently  and  snugly  into  place  with  a  probe.  To  make  removal  easy  and 
certain  they  are  tied  at  interv^als  to  a  string  whose  end  is  external  to 
the  anterior  narcs.  If  their  use  is  inadequate,  then  the  posterior  nares 
must  be  subjected  to  like  treatment,  and  if  the  details  are  well  in  mind 
it  is  not  a  difficult  procedure. 

Passing  the  index  finger  behind  the  velum,  the  surgeon  notes  the 
exact  location  and  size  of  the  aperture  to  be  plugged  and  the  presence 
of  abnormalities  if  any  exist.  The  most  convenient  instrument  for  this 
operation  is  Bellocq's  cannula  (Fig.  253).     If  it  is  not  at  hand,  a  soft- 


Fu;.  253. — Bellocq's  cannula  for  epistaxis. 

rubber  catheter  serves  the  purpose.  This,  thoroughly  disinfected,  is 
threaded  with  a  stout  sterilized  thread  of  good  length  and  passed  along 
the  floor  of  the  nose  until  it  enters  the  pharynx  and  can  be  seen.  One 
end  of  the  thread  is  then  brought  out  through  the  mouth  by  means  of 
a  pair  of  forceps,  and  the  catheter  is  withdrawn  from  the  nose.  The 
string  is  now  in  position.  A  plug  of  antiseptic  cotton  or  sponge  is  then 
fastened  to  the  string,  guided  through  the  mouth  and  pharynx  by  the 
surgeon's  finger,  and  fixed  firmly  in  position  in  the  posterior  nares  by 
traction  on  the  string  through  the  nostril,  aided  by  gentle  pressure  with 
the  finger  from  behind.  The  ends  of  the  string  are  now  tied.  When 
the  plug  is  to  be  removed  gentle  traction  on  the  end  of  the  string  which 
emerges  from  the  mouth  is  usually  sufficient.  If  desirable,  anterior 
plugs  may  be  placed  in  position  after  the  posterior  nares  is  fitted. 

To  avoid  decomposition  and  consequent  ulceration  none  of  these 
should  remain  in  situ  longer  than  two  full  days.  If  epistaxis  still 
threaten,  the  operation  must  be  repeated  after  using  antiseptic  and 
astringent  douches.  Appropriate  constitutional  treatment  should  be 
maintained  meanwhile. 

Ulcers. — Simple  catarrhal  ulceration  as  a  result  of  acute  or  chronic 
coryza  is  a  rare  thing,  and  consists  of  nothing  more  than  an  erosion  of 
the  mucous  membrane  easily  amenable  to  cleanliness,  antisepsis,  and 
general  remedies. 

Ulceration  is  common  when  two  mucous  surfaces  are  brought 
together,  as  in  deviated  septum,  hypertrophy  or  pressure  of  the  sur- 
faces of  two  polypi,  or  other  benign  tumors  pressing  against  the  sep- 
tum. Removal  of  the  cause  disposes  of  them.  Surfaces  of  malignant 
growths  are  especially  prone  to  ulceration,  both  from  the  same  causes 
that  produce  ulceration  of  such  growths  in  other  parts  of  the  body, 
and  from  the  fact  that  they  are  quickly  subjected  to  pressure  from  the 
relatively  small  space  in  which  they  develop.  Bleeding  and  offensive 
discharge  are  the  symptoms  of  ulceration. 

Extirpation  of  the  malignant  growths  is  their  only  cure,  but  much 
may  be  done  to  make  the  patient  more  comfortable  and  the  pain  en- 


INJURIES  AND  DISEASES   OF  THE   RESPIRATORY  SYSTEM.    567 

durable  if  the  necrotic  tissue  be  thoroughly  removed  by  curette, 
cautery,  or  knife. 

TranniatisjH,  as  from  the  introduction  of  foreign  bodies,  may  pro- 
duce ulcers  that  will  disappear  with  the  cause.  Exhausting  diseases,  as 
severe  fevers,  small-pox,  scarlet  fever,  or  scurvy,  may  produce  ulcera- 
tion in  the  nasal  cavity.  Rodent  ulcer,  beginning  externally,  may  be 
so  sev'ere  as  to  destroy  the  entire  nasal  organ,  or,  if  checked,  may 
impede  respiration  by  its  cicatricial  tissue. 

Modern  scientific  research  has  declared  the  bacillus  of  tuberculosis 
and  that  of  lupus  to  be  identical,  so  that  they  must  be  regarded  as 
different  manifestations  of  the  same  disease.  The  former  is  said  to  be 
very  rare  as  a  lesion  in  the  nasal  cavity,  only  a  few  cases  having  been 
reported,  and  none  at  all  until  1S77.  Even  of  these  rare  cases  only 
one  or  two  were  absolutely  proven  to  be  primary.  The  nodules  or 
tubercles  are  at  first  of  a  grayish  color  and  are  covered  with  epithelium. 
When  this  is  softened  ulceration  occurs,  nodules  and  small  ulcers  exist- 
ing side  by  side.  There  is  increased  secretion,  but  the  pain  is  insig- 
nificant, and  obstruction  seldom  takes  place. 

Diagnosis  depends  upon  microscopical  examination. 

Prognosis. — Life  is  not  endangered  by  the  mere  presence  of  tuber- 
culosis in  the  nasal  cavity.  In  most  cases  it  is  secondary  to  an  ad- 
vanced stage  of  the  disease  in  other  parts  of  the  body.  If  primary, 
removal  by  the  curette  or  wire  loop,  though  difficult,  might  eradicate 
the  disease,  but  it  generally  recurs. 

Antiseptic  douches  or  the  insufflation  of  powders  may  contribute  to 
comfort.  Radical  extirpation  is  the  only  cure,  and  usually  this  is  not 
advisable,  considering  the  general  condition  qf  the  patient. 

lyUpus  on  the  cutaneous  surface  of  the  nose  is  a  serious  matter, 
because  of  the  cicatricial  tissue  resulting  from  its  ravages,  and  the 
consequent  effect  upon  respiration.  If  it  occur  as  a  primary  lesion  on 
mucous  membrane,  scars  are  less  common  and  thorough  eradication 
comparatively  sure. 

Lupus  must  be  differentiated  from  epithelioma  and  sarcoma,  and 
particularly  from  syphilis.  Sarcomata  grow  very  rapidly  and  are 
usually  not  multiple. 

Hpitheliomata  begin  as  tiny  papillomata,  and  even  break  down 
in  ulceration  with  involvement  of  neighboring  glands.  Microscopical 
examination  will  establish  the  character  of  sarcomata  or  epitheliomata. 

The  diagnosis  from  syphilis  presents  peculiar  difficulties,  and  may  be 
settled  by  recourse  to  specific  treatment.  The  age  of  the  patient,  his- 
tory of  the  case,  absence  of  signs  of  syphilis  in  other  parts  of  the 
body,  the  slow  advance  of  the  disease,  the  tendency  to  heal  in  one 
place  and  progress  in  another,  and  the  fact  that  necrosis  of  bone  occurs 
at  a  late  stage  in  the  disease,  are  points  to  be  taken  into  consideration 
in  differentiating  lupus  from  syphilis  in  the  nasal  cavities. 

Treatment. — Thorough  eradication  is  the  only  course.  This  may  be 
accomplished  by  scraping  or  curetting,  followed  by  caustic  applications 
to  ensure  complete  removal  of  the  tissue.  Some  authorities  advocate 
the  application  of  caustics  alone ;  zinc  chloride,  potassic  hydrate, 
chromic  acid,  lactic  acid,  silver  nitrate,  terchloracetic  acid  are  all  of  use 
in  different  cases. 


568  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

Tlic  galvano-cautery,  the  actual  cautery,  multiple  scarification,  and 
puncture  are  possible  methods  of  eradication.  The  irritation  set  up  by 
any  of  these  radical  measures  should  be  treated  on  the  general  princi- 
ples for  allaying  inflammation. 

S5T)hilis  in  the  nasal  cav^ities  is  far  from  unccmimon,  though 
doubtless  its  manifestation  in  the  tertiary  stage  is  much  more  frequent 
than  in  either  of  the  others.  Chancre  of  the  nasal  passages  has  been 
occasionally  reported,  and  Burow  has  drawn  attention  to  several  cases 
due  to  infection  by  Eustachian  catheters.  The  commonest  manifestation 
of  secondary  syphilis  is  simply  an  acute  coiyza  of  persistent  type. 
This  may  be  the  only  symptom,  and  so  rarely  are  mucous  patches  seen 
on  the  nasal  mucous  membrane  that  their  existence  there  has  been 
doubted.  However,  they  may  be  found — upon  the  septum  as  a  rule, 
and  not  so  near  the  junction  of  skin  and  mucous  membrane  as  is  the 
case  on  the  buccal  mucous  membrane.  Ulceration  is  never  deep,  unless 
it  is  in  the  latter  part  of  the  secondary  stage,  when  the  early  indications 
of  the  tertiary  stage  may  be  suspected. 

It  is  in  the  tertiary  stage  of  syphilis  that  its  presence  in  the  nasal 
passages  is  most  plainly  and  seriously  manifested.  Gummata  form 
either  upon  the  periosteum  or  occur  as  an  infiltration  in  the  mucous 
membrane.  Upon  the  septum  they  occasion  little  pain,  but  upon  the 
turbinated  bones  they  are  somewhat  painful.  They  may  obstruct 
respiration,  and  on  examination  they  may  at  first  be  mistaken  for  other 
tumors,  as  they  show  little  tendency  to  ulceration.  However,  the  gen- 
eral condition  of  the  patient  is  usually  such  as  to  leave  no  room  for 
doubt  as  to  the  character  of  the  tumor.  When  ulceration  begins 
destruction  of  tissue  goes  on  very  rapidly.  Perforation  of  the  septum 
is  an  early  result  of  gummatous  periostitis,  and  its  complete  obliteration 
may  rapidly  follow.  The  turbinated  bones,  the  vomer,  the  perpendicular 
plate  of  the  ethmoid,  and  the  roof  and  floor  of  the  nose  are  destroyed. 
Perforation  of  the  hard  palate  is  not  uncommon,  either  by  extension 
from  the  nose  or  else  from  independent  gummata  in  its  periosteum. 
The  cartilaginous  tissues  are  rapidly  destroyed  as  well.  This  of  course 
leads  to  great  deformity,  and  the  cranial  cavity  may  be  invaded,  and 
very  rarely  septicemia  may  follow  from  exposure  of  bone.  While  this 
rapid  destruction  is  going  on  bits  of  necrosed  bone  and  shreds  of  tissue 
either  block  the  passages  or  are  discharged  with  the  secretion,  which  is 
bloody  and  purulent-fetid  to  an  almost  intolerable  degree. 

The  kind  and  amount  of  deformity  depend  upon  the  location  of  the 
first  gummata  and  the  point  at  which  the  process  of  destruction  is  stayed. 
Slight  perforation  of  the  septum  or  destruction  of  the  turbinated  bone 
may  not  produce  deformity.  If  necrosis  proceed  farther  than  this,  a 
varying  degree  of  deformity  will  result,  even  to  complete  obliteration 
of  the  nose.  Contiguous  bones,  as  the  malar  or  maxillary  or  palate, 
are  occasionally  destroyed,  but  this  may  be  due  to  original  infiltration 
into  their  own  substance  rather  than  to  extension  from  the  nose. 

The  diagnosis  of  syphilitic  lesions  in  the  nasal  passages  presents  few 
difficulties.  The  history  of  the  case  and  the  presence  of  the  syphilitic 
cachexia  are  sufficient  to  establish  the  diagnosis.  Lupus,  cancer,  or 
ozena  may  be  mistaken  for  syphilis.  The  microscope  or  specific  treat- 
ment will  differentiate  the  first  two  (together  with  the  history  of  the 


INJURIES  AND  DISEASES   OF  THE  RESPIRATORY  SYSTEM.    569 

case,  age  of  the  patient,  and  absence  of  characteristic  cachexia).  The 
foul  odor  of  ozena  may  be  taken  for  syphiHs  in  the  secondary  stage, 
but  douching  and  syringing  will  temporarily  remove  the  odor  of  ozena, 
whereas  the  decaying  tissue  in  syphilis  gives  a  persistent  odor. 

Prognosis  in  all  respects  is  favorable  in  the  secondary  stage  and  at 
any  time  before  necrosis  of  bone  has  commenced.  When  this  has  been 
established  the  prognosis  is  serious  as  to  future  deformity.  As  to  life, 
it  is  the  same  as  for  the  tertiary  stage  generally  under  the  same 
conditions. 

Treatment  must  be  both  local  and  constitutional,  the  first  to  limit  the 
ravages  of  the  disease  in  the  nasal  cavity,  the  latter  to  effect  a  complete 
cure. 

If  the  local  manifestation  is  only  that  of  an  acute  coryza,  antiseptic 
sprays  and  syringing,  combined  with  the  use  of  mercury,  will  be  suffi- 
cient. To  mucous  patches  some  caustic  must  be  applied.  If  a  gumma 
has  not  begun  to  ulcerate,  constitutional  treatment  should  be  pushed 
in  the  hope  of  causing  its  absorption  before  ulceration  with  its  conse- 
quent necrosis  takes  place.  If  necrosis  has  begun,  cleansing  and 
removal  of  dead  tissue  must  be  most  thorough.  Ulcers,  even  if 
superficial,  should  be  cleansed  and  disinfected  regularly  and  frequently. 
If  they  are  deep,  more  energetic  measures  are  necessary,  even  to 
curetting.  The  discharge  should  be  checked  and  all  scales  and  crusts 
removed.  If  the  bone  has  been  attacked,  all  detached  portions  must  be 
removed,  for  they  act  like  foreign  bodies,  maintaining  a  constant  irrita- 
tion. They  may  be  loosened  from  their  positions  by  a  strong  spray  or 
syringe  in  some  cases,  but  generally  the  probe  or  forceps  must  be 
employed. 

If  a  portion  of  necrosed  bone  has  even  slight  attachment,  it  is  gen- 
erally best  not  to  use  force  in  separating  it,  but  to  wait  for  further 
necrosis  to  loosen  it  completely,  because  of  the  danger  of  hemorrhage. 

After  the  parts  have  been  thoroughly  cleansed  an  insufflation  of 
iodoform  may  be  used. 

lodid  of  potassium  in  full  doses  three  or  four  times  a  day,  with  or 
without  mercury,  constitutes  the  treatment.  Cod-liver  oil,  iron,  and 
other  tonics  may  be  indicated  if  the  patient  is  greatly  reduced.  Various 
rhinoplastic  operations  may  be  resorted  to  with  the  view  of  concealing 
or  repairing  deformities,  or  an  artificial  nose  may  be  worn. 

In  hereditary  syphilis  the  infant  appears  at  first  to  be  merely  suf- 
fering from  a  severe  attack  of  acute  coryza  with  profuse  discharge,  or 
is  said  to  have  the  "  snuffles."  Other  indications  of  syphilis  are,  how- 
ever, usually  present  in  the  old  look  and  emaciated  condition  of  the 
child,  in  the  hoarse  cry,  cutaneous  eruptions,  and  mucous  patches  on 
tongue,  cheeks,  lips,  and  around  the  anus.  The  discharge  becomes 
muco-purulent  and  excoriates  the  lip  and  nose. 

In  the  coryza  of  infantile  syphilis  the  mucous  membrane  is  hyper- 
emic  and  swollen,  and  there  is  a  thin,  watery  discharge.  This  condi- 
tion so  interferes  with  respiration  that  nursing  becomes  difficult,  and 
adequate  nourishment  of  the  child  is  almost  impossible.  Constitutional 
treatment  must  at  once  be  begun,  supplemented  by  thorough  and  sys- 
tematic cleansing  of  the  nasal  passages  by  antiseptic  sprays.  If  the 
thickened  discharge  completely  blocks  the  nasal  passages,  the  accu- 


570  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

mulatcd  secretion  may  be  forced  from  one  nostril  by  the  compression 
of  air  in  a  rubber  ball  within  the  other.  The  excoriated  portions  of 
skin  must  be  dressed  with  soothin<^  applications.  A  child  thus  afflicted 
should  not  be  allowed  to  nurse  the  breast  of  one  untainted  with  the 
disease  nor  use  drinking  vessels  to  which  others  have  access. 

If  the  health  of  the  child  be  not  too  completely  undermined,  vigor- 
ous treatment  from  the  time  of  the  first  indications  of  the  disease — 
usually  within  the  first  month  of  life  and  seldom  later  than  the  third — 
may  prevent  its  further  development.  As  a  rule,  however,  it  goes  on  to 
the  third  stage,  when  the  same  course  of  treatment  must  be  adopted  as 
for  adults,  and,  should  the  child  surviv'c  this  period,  it  is  rare  indeed 
that  it  escapes  all  evidences  of  the  ravages  of  the  disease. 

The  ulcers  of  leprosy  in  the  nasal  cavity  are  not  unknown.  They 
are  similar  to  those  found  in  other  parts  of  the  body.  Cleanliness  and 
antiseptic  sprays  will  lessen  in  some  degree  their  offensive  character. 

They  are  found  only  when  the  whole  system  is  invaded  and  under- 
mined by  the  disease.     Treatment  is  of  no  avail. 

Rhinitis. — Acute. — This  is  the  condition  produced  by  an  acute 
inflammation  of  the  pituitary  membrane.  There  is  tumefaction  accom- 
panied or  followed  by  a  secretion,  at  first  thin  and  acrid,  later  of  a 
thicker  consistency,  due  to  discharge  of  epithelial  debris.  In  the  last 
stage  of  rhinitis  the  secretion  again  becomes  thin,  and  disappears  as  the 
nasal  mucous  membrane  returns  to  its  normal  condition. 

The  commonest  form  of  rhinitis  is  that  known  as  "  cold  in  the 
head,"  due  to  sudden  chilling  of  some  portion  of  the  body.  Other 
causes  less  generally  recognized  may  also  produce  an  acute  coryza. 
That  caused  by  syphilis  is  discussed  elsewhere.  It  is  quite  frequently 
a  symptom  of  the  early  stages  of  the  exanthemata  and  influenza.  It 
may  also  be  due  to  inhalation  of  irritating  gases,  as  bromin,  also  to 
powders,  dust,  and  odors — to  the  pollen  of  plants,  as  in  that  condition 
popularly  known  as  "  hay  fever."  It  is  set  up  by  the  presence  of 
foreign  bodies  and  growths  in  the  nasal  cavities,  and  by  extension 
from  other  mucous  membranes,  as  from  the  conjunctiva.  The  internal 
administration  of  certain  drugs,  particularly  iodid  of  potassium,  will 
also  produce  it.  It  often  occurs  at  the  same  time  with  asthma.  It  is 
impossible  also  from  its  epidemic  character  at  times  to  escape  the  con- 
clusion that  its  origin  may  be  microbic.  This  may  almost  be  assumed 
when  it  is  only  a  forerunner  of  an  acute  general  disease  that  develops 
later. 

Symptoms. — There  may  be  no  sign  of  the  presence  of  an  acute 
coryza  until  the  patient  begins  to  sneeze  or  until  the  discomfort  arising 
from  the  congestion  and  the  swelling  of  the  membrane  is  noticed.  In 
most  persons,  particularly  in  the  case  of  the  aged  and  feeble  or  if  the 
exposure  be  prolonged  or  severe,  a  marked  chill  may  be  present  or  at 
least  a  feeling  of  chilliness.  This  is  followed  by  a  rise  in  temperature, 
usually  somewhat  proportionate  to  the  severity  of  the  chill.  In  some 
cases  there  is  a  general  feeling  of  malaise,  or  the  whole  body  may  ache 
as  a  preliminary  symptom.  Frontal  headache  is  common.  In  any 
case,  after  the  congestion  of  the  mucous  membrane  has  lasted  a  few 
hours,  the  discharge  of  the  secretions  begins,  assuming  the  characters 
noted  above. 


INJURIES  AND   DISEASES   OF  THE  RESPIRATORY  SYSTEM.    5/1 

Nasal  respiration  may  become  impossible ;  smell  and  taste  lose 
their  acuteness.  Commonly,  these  symptoms  increase  in  severity  for 
two  or  three  days,  then  begin  slowly  to  disappear.  However,  by  the 
involvement  of  other  structures  the  case  may  become  much  more 
complicated.  By  extension  the  pharynx  may  be  involved,  producing 
"  sore  throat."  The  frontal  sinuses,  the  antrum  of  Highmore,  the  nasal 
duct,  the  Eustachian  tube  may  all  be  affected  to  a  greater  or  less  degree, 
each  giving  the  characteristic  symptoms  of  inflammation  in  that  locality. 
Discomfort  and  uneasiness,  rather  than  pain,  are  the  symptoms  of  un- 
complicated acute  coryza.  If  the  complications  just  mentioned  are 
severe,  pain  becomes  a  marked  feature. 

Treatment. — Many  cases  of  acute  coryza  require  little  or  no  treat- 
ment, for  the  disease,  unless  it  is  a  part  of  some  acute  general  malady, 
runs  its  own  course  in  a  few  days.  Often,  however,  slight  exposure, 
after  it  has  once  commenced,  adds  to  its  intensity  or  brings  on  a  relapse 
after  convalescence  has  begun,  so  that  the  case  becomes  very  protracted 
unless  checked  by  prompt  treatment.  This  may  be  both  local  and 
general,  both  abortive  and  curative. 

Quinin  in  large  doses  sometimes  aborts  a  "  cold,"  particularly  if 
sudorific  treatment  is  combined  with  it.  Tincture  of  aconite  is  used  for 
the  same  purpose.  A  recent  writer  recommends  the  use  of  bicarbonate 
of  soda  to  abort  a  "  cold,"  on  the  theory  that  the  Schneiderian  mem- 
brane is  irritated  by  some  acid  in  the  blood.  Fifteen  to  thirty  grains 
are  given  in  water  every  half  hour  until  three  doses  have  been  taken, 
and  a  fourth  dose  at  the  end  of  an  hour.  At  the  end  of  three  or  four 
hours  these  doses  are  repeated  if  there  are  still  left  any  signs  of  the 
coryza.  Even  a  third  or  a  fourth  trial  may  be  made  at  suitable  intervals 
if  desired. 

Cathartics  at  night,  followed  by  a  saline  purge  in  the  morning,  is 
good  treatment,  whether  the  object  is  to  abort  or  cure.  With  the  first 
object  in  view  opium  in  \-  to  ^-gr.  doses  may  be  taken.  Dover's  powder 
both  reliev^es  pain  and  produces  sweating.  Some  form  of  belladonna 
may  also  be  combined  with  the  opium. 

Hot  drinks,  a  hot  mustard  foot-bath,  after  which  the  patient  is  kept 
very  warm  in  bed  for  several  hours,  will  in  many  cases  be  sufficient  to 
cut  short  a  threatened  attack  of  acute  coryza,  especially  if  it  is  due  to 
exposure  to  cold  only.  To  this  may  be  added  the  inhalation  of  steam, 
medicated  or  otherwise.  A  sponge  saturated  with  the  hot  liquid  is  held 
to  the  nose,  and  through  it  the  patient  breathes.  Persons  accustomed 
to  them  find  Turkish  baths  useful  in  aborting  a  cold. 

However,  after  the  corj'za  is  fairly  established  measures  to  control 
and  limit  inflammation  are  indicated,  both  internally  and  locally. 
Phenacetin,  antipyrin,  lactophenin,  or  aconite  may  be  used  to  control 
the  fever.  Atropin  or  belladonna  and  opium  are  useful  in  the  later 
stages,  as  in  the  beginning. 

Astringents,  locally  applied,  are  of  little  use  in  acute  coryza,  their 
value  being  greater  in  the  chronic  form ;  cocain,  either  as  a  spray  or  as 
a  powder,  is  far  better.  A  powder  composed  of  subnitrate  of  bismuth, 
with  a  little  morphin,  inserted  as  an  insufflation  occasionally  gives  great 
relief  Silver  nitrate  used  in  the  same  way  is  recommended.  If  the 
discharge  becomes  muco-purulent,  antiseptic  spray  may  be  used.    Rhi- 


5/2  SURGICAL   DIAGNOSIS   AND    TREATMENT. 

nitis  due  to  irritating  vapors  yields  to  the  administration  of  opium.  In 
the  acute  form  of  rhinitis,  known  as  hay,  rose,  or  June  fever  or  the 
catarrh  of  autumn,  no  specific  treatment  is  known,  and  what  avails 
with  one  patient  may  be  of  no  use  to  another  or  with  the  same  person 
at  another  time.  Change  of  climate  is  probably  of  more  service  than 
any  other  one  thing,  and  general  nutrition  must  be  kept  at  as  high  a 
point  as  possible. 

Opium  should  not  be  employed  in  the  acute  coryza  of  childhood. 
Care  must  be  taken  to  see  that  the  nourishment  of  the  child  is  main- 
tained, ev^en  if  feeding  through  a  tube  is  necessary.  A  soft-rubber  tube 
may  be  inserted  into  the  nostril  if  there  is  severe  dyspnea. 

Chronic. — Different  clinical  aspects  of  chronic  inflammation  suggest 
a  simple  classification.  If  there  is  a  simple  catarrh  without  structural 
alterations,  it  is  known  as  chronic  nasal  catarrh,  coryza,  or  chronic  rhi- 
nitis. If  the  Schneiderian  membrane  and  the  underlying  structures  are 
thickened  and  enlarged,  it  is  called  Jiypcrtropliic  catarrJi  or  hypertrophic 
rhinitis.  If,  on  the  other  hand,  the  nasal  passages  are  unusually  wide 
and  open,  the  turbinated  bones  small,  and  the  overlying  tissues  thin  and 
atrophied,  the  condition  is  known  as  atropine  nasal  catarrh. 

Simple  nasal  catarrh  is  generally  due  either  to  an  acute  attack  w^hich 
does  not  go  on  to  complete  recovery,  but  which,  neglected  or  improp- 
erly treated,  continues  with  mitigated  sev^erity,  or  to  the  habit  or  con- 
dition established  by  repeated  acute  attacks,  perhaps  in  a  patient  pecu- 
liarly susceptible.  The  symptoms  are  mainly  those  of  the  acute  attack 
modified  and  lessened  in  severity.  If  it  confines  itself  strictly  within 
the  limits  implied  in  its  definition,  it  is  scarcely  to  be  considered  in 
itself  a  surgical  disease  at  all,  but  comes  more  properly  within  the 
domain  of  the  medical  therapeutist.  However,  it  is  so  frequently  the 
precursor,  if  not  the  cause,  of  the  other  forms  of  chronic  rhinitis  that 
it  must  not  be  overlooked.  It  is  rare  indeed  that  a  long-continued 
simple  nasal  catarrh  does  not  involve  the  naso-pharynx  and  the  poste- 
rior pharynx.  So  generally  is  this  true  that  with  some  authors  a 
chronic  coryza  is  understood  to  include  a  retronasal  and  a  retropharyn- 
geal catarrh.  In  such  a  condition  as  this  the  Schneiderian  membrane 
is  not  thickened,  although  the  vault  and  posterior  pharynx,  owing  to 
the  large  amount  of  glandular  tissue,  may  be  somewhat  hypertrophied, 
giving  rise  to  a  large  amount  of  thick  mucous  secretion.  By  extension 
also  the  Eustachian  tube  may  become  involved,  and  partial  or  complete 
deafness,  either  temporary  or  permanent,  follow. 

True  hypertrophic  nasal  catarrh  consists  of  a  thickening  of  the  epi- 
thelium of  the  pituitaiy  membrane,  and  also  of  the  underlying  adenoid 
and  connectiv^e  tissues,  together  wath  enlargement  and  dilatation  of 
blood-vessels.  The  nasal  mucous  membrane  is  well  supplied  with 
glandular  tissue,  and  the  distention  of  the  mucous  glands  is  no  small 
factor  in  the  hypertrophy  of  this  membrane. 

The  secretion  is  thick  and  viscid,  and  is  generally  increased  in  amount, 
though  the  discomfort  from  its  presence  in  the  narrowed  passages  and 
the  constant  efforts  at  removal  may  make  it  appear  excessive  when  it 
is  really  normal  or  diminished.  Sensibility  and  smell  are  impaired ; 
nasal  respiration  is  interfered  with ;  retronasal  and  retropharyngeal 
catarrh  are  practically  the  accompaniments  of  this  disease. 


INJURIES  AND  DISEASES   OF  THE  RESPIRATORY  SYSTEM.    573 

The  lower  and  middle  turbinate  bones  are  the  ones  most  affected, 
particularly  the  lower.  The  membrane  over  these  bones,  as  viewed 
from  the  anterior  nares,  is  hyperemic  and  swollen,  and  upon  the  lower 
of  a  dark-red  color  that  brightens  up  somewhat  in  the  middle.  The 
hypertrophy  is  neither  wholly  smooth  nor  regular,  but  is  raised, 
inclined  to  be  nodular,  and  of  irregular  outline.  It  may  be  so  great 
as  to  extend  from  the  turbinate  bones  across  to  the  septum  and  de- 
pend toward  the  floor.  In  such  a  case  respiration  would  be  com- 
pletely obstructed  from  the  blocking  up  of  the  anterior  nares.  Ob- 
struction to  respiration  is  more  apt,  however,  to  occur  from  hyper- 
trophy of  the  membrane  around  the  posterior  nares  than  from  the 
anterior  nares,  for  it  is  most  pronounced  in  the  retronasal  region  at  the 
posterior  portions  of  the  inferior  turbinated  bones.  If  there  is  a  deviated 
septum,  early  irritation  of  its  protruded  portion  by  the  encroaching 
spongy  tissue  of  the  hypertrophy  may  cause  also  hypertrophy  at  that 
point,  particularly  opposite  the  posterior  end  of  the  inferior  turbinated 
bone,  and  impede  respiration  very  early  in  the  progress  of  the  disease. 
The  appearance  of  the  membrane  posteriorly  is  paler  than  at  the  ante- 
rior end  of  the  turbinated  bones  ;  also  above  it  is  less  vivid  in  color. 
The  middle  turbinated  bone  may  not  be  involved  at  all,  or  the  membrane 
may  be  so  grossly  hypertrophied  as  to  resemble  a  polypus. 

Since  the  result  of  chronic  inflammation  in  other  parts  of  the  body 
is  hypertrophy,  analogy  forces  the  inference  that  hypertrophic  nasal 
catarrh  is  no  exception.  Acute  coryza  is  followed  by  the  simple 
chronic  form,  and  this,  if  unrelieved,  gradually  merges  into  genuine 
hypertrophy.  This  seems  to  be  the  history  of  this  condition,  although 
some  observers  claim  that  the  acute  and  chronic  coryzas  which  ap- 
parently precede  and  cause  the  hypertrophy  are  simply  early  and  cha- 
racteristic manifestations  of  the  incipient  hypertrophy.  Without  doubt 
the  rapid  and  extreme  changes  of  climate  that  are  characteristic  of 
most  parts  of  the  temperate  zone  are  to  be  reckoned  as  factors. 

Occupation  in  trades  or  arts  where  irritating  vapors  or  dust  are  con- 
stantly present  may  be  a  cause. 

The  symptoms  are  the  obstruction  to  nasal  respiration,  the  thick 
discharge,  impairment  of  sensibility,  smell,  and  perhaps  hearing ;  when 
the  inflammation  has  extended  to  the  pharynx  there  may  be  a  change 
in  the  quahty  of  the  voice,  sore  throat,  coryza  and  hawking  and  raising 
of  mucus.  In  cases  of  long  standing  the  inflammation  will  extend  to 
the  larynx  and  trachea,  with  additional  symptoms  referable  to  those 
parts. 

Anterior  and  posterior  rhinoscopy  will  reveal  the  pathological  con- 
ditions in  the  nares  already  described,  usually  bilateral. 

The  vault  of  the  pharynx  has  been  called  "  the  pharyngeal  tonsil " 
because  of  the  abundance  of  its  glandular  tissue.  So  prone  is  this  to 
hypertrophy  that  adenoid  vegetations  as  the  result  of  inflammation  are 
exceedingly  common,  and  hypertrophic  nasal  catarrh  is  believed  some- 
times to  originate  by  extension  from  pharyngeal  inflammation,  and  may 
become  very  extensive — so  much  so  that  the  vault  and  the  posterior 
pharynx  are  completely  filled  with  the  adenoid  hypertrophies,  and  can 
be  seen  through  the  mouth  by  lifting  the  edge  of  the  velum. 

In  the  majority  of  cases,  however,  such  excessive  hypertrophies  are 


574  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

not  found,  but  there  is  marked  thickening  of  the  membrane,  even  so 
much  that  it  Hes  in  ridges.  The  hypertrophied  mass  is  soft  and  varies 
in  color  from  a  flesh  tint  to  a  turgid  red.  As  a  general  thing  such 
hypertrophies  are  found  only  in  children   and  young  adults. 

Diag)iosis  is  easy  from  the  symptoms  and  careful  rhinoscopy. 
Hypertrophy  of  the  nasal  mucous  membrane  at  first  glance  might 
resemble  polypi,  but  the  latter  usually  are  pedunculated  and  originate 
on  the  upper  part  of  the  middle  turbinated  bone.  Perichondritis  is 
more  apt  to  begin   on  the  septum. 

Prognosis  is  good  as  regards  life  and  relief  from  the  disease,  and 
recovery  may  be  complete.  Most  observers  claim,  however,  that  long- 
continued  hypertrophic  rhinitis  terminates  generally  in  the  atrophic 
form  of  rhinitis. 

Treatment. — Clinically,  as  regards  treatment,  cases  of  hypertrophic 
rhinitis  fall  naturally  into  two  classes — those  in  which  the  process  is 
only  slight  and  which  may  be  checked  by  topical  applications  of  one 
sort  or  another,, and  those  in  which  the  hypertrophic  process  has  pro- 
gressed more  extensively  and  decidedly,  and  in  which  removal  of 
redundant  tissue  by  instruments  or  caustics  is  the  only  suitable  measure. 

In  either  case  there  must  be  thorough  cleansing  of  the  passages  of 
the  secretion  and  of  crusts,  though  the  latter  are  not  common.  This 
may  be  accomplished  in  many  cases  by  the  patient's  blowing  his  nose, 
and  where  possible  this  is  the  better  way,  because  it  is  less  irritating  to 
the  delicate  and  sensitive  membranes. 

In  case  the  aid  of  a  surgeon  is  required  he  has  at  his  command 
both  instruments  and  the  spray.  The  probe  with  a  bit  of  cotton  at  the 
end  may  be  used  to  remove  adherent  secretions.  No  great  force  should 
at  any  time  be  used,  but  it  may  be  necessaiy  gently  to  push  aside  the 
obtruding  parts  in  order  to  make  a  way  for  the  entrance  of  the  spray. 
Generally,  however,  unless  the  hypertrophy  be  very  great  a  solution 
of  cocain  will  sufficiently  contract  the  membrane  to  afford  a  passage  for 
the  spray.  A  coarse  spray  of  some  alkaline  solution  is  the  one  com- 
monly used  for  cleansing.  For  the  removal  of  the  tenacious  mucus  in 
the  vault  of  the  pharynx  or  at  the  posterior  nares  a  nasal  syringe  may 
be  more  serviceable.  In  the  first  class  of  cases,  where  the  hypertrophy 
is  only  slight,  after  thorough  cleansing  astringent  and  antiseptic 
remedies  may  be  used,  preferably  in  the  form  of  a  solution  through  the 
nasal-spray  apparatus.  Soluble  bougies,  ointments,  and  snuffs  each  have 
their  advantages  in  certain  cases,  particularly  as  no  apparatus  is  neces- 
sary for  their  application.  Gradual  dilatation  with  bougies  is  a  possible 
mode  of  treatment,  and,  when  combined  with  systematic  cleansing  and 
local  treatment,  may  be  of  value. 

As  a  rule,  it  is  the  more  pronounced  cases  which  come  into  the 
surgeon's  hands,  those  where  there  is  much  redundant  tissue,  where 
occlusion  of  the  nasal  passages  is  almost  wholly  complete,  and  where 
nasal  respiration  is  nearly  or  quite  impossible.  In  order  to  restore 
respiration  the  removal  of  tissue  in  one  or  both  nostrils  is  indicated, 
and  here  the  surgeon  has  his  choice  either  of  instrumental  interference 
or  of  caustics. 

Cocain  is  first  used  to  anesthetize  the  parts.  Caustics  may  be  ap- 
plied on  a  bit  of  cotton,  the  greatest  caution  being  observed.     Chromic 


INJURIES  AND    DISEASES   OF   THE  RESPIRATORY  SYSTEM.    $J$ 

acid,  nitric  acid,  glacial  acetic  acid,  or  trichloracetic  acid  will  serve  the 
purpose.  Nitrate  of  silver  is  slow  in  action,  and  also  has  a  stimulating 
effect — ^just  what  is  not  desired — and  is  now  seldom  used.  Alkaline 
washes  should  follow  the  application  of  any  of  these  acid  escharotics. 

The  galvano-cautery  under  skilful  manipulation  does  good  service, 
and  instruments  of  different  shapes,  suited  to  the  cavity  and  to  the  tissue 
to  be  removed,  can  be  adjusted  to  the  various  electrodes.  It  is  not, 
however,  of  univ^ersal  application — as,  for  instance,  at  the  posterior 
extremity  of  the  inferior  turbinated  bone  it  is  not  always  possible  to 
estimate  precisely  the  degree  of  heat,  and  too  extensive  and  too  deep 
an  eschar  may  be  produced. 

Electricity  is  said  also  to  sometimes  produce  anosmia,  and  sometimes 
perversion  of  smell.  Until  sloughing  and  healing  of  the  surface  are 
complete,  cleanliness  and  asepsis  must  be  carefully  maintained,  as  is 
also  the  case  when  chemical  caustics  are  used.  Besides  the  relief 
gained  immediately  by  the  removal  of  tissue,  much  may  be  hoped 
from  the  subsequent  contraction  of  the  cicatrix. 

In  most  cases,  however,  some  instrument  which  cuts  away  the 
redundant  tissue  without  profuse  hemorrhage  provides  the  most  de- 
sirable method  of  treating  the  membrane  in  hypertrophic  rhinitis.  Of 
these  the  ecraseur — of  which  Jarvis's  snare  is  the  best  form — is  the 
most  satisfactory  (Fig.  240).  After  careful  study  of  the  location  of  the 
parts  the  wire  loop  is  slipped  over  the  portion  to  be  removed,  tightened 
around  it,  and  then  slowly  made  to  cut  its  way  through.  Scissors  or 
forceps  may  be  employed,  but  the  tearing  of  the  forceps  is  painful  and 
the  bleeding  profuse.  In  the  vault  of  the  pharynx  a  sharp  spoon, 
curette,  or  sharp-bladed  cutting  forceps,  if  the  vegetations  are  anything 
more  than  slight  thickening,  may  be  used.  New  blood-vessels  are  a 
characteristic  feature  of  rapidly-forming  hypertrophic  tissue,  and  scari- 
fication or  puncture  by  destroying  these  may  put  an  end  to  the  process. 
If  there  is  much  hemorrhage,  whatever  the  mode  of  treatment,  appli- 
cation of  hot  water  should  first  be  tried.  If  bleeding  is  excessive,  plug- 
ging of  the  nares  must  be  resorted  to. 

Atrophic  Nasal  Catarrh. — In  this  disease  instead  of  hyper- 
trophied  tissues  and  occluded  passages  there  is  present  precisely  the 
opposite  condition — atrophied  tissues  and  abnormally  wide  nasal  pas- 
sages. Nevertheless,  most  authorities  claim  that  the  last  condition  is 
only  a  secondary  phase  of  the  first.  In  fact,  all  shades  of  opinion  find 
expression.  By  some  it  is  held  that  it  never  exists  as  the  result  of 
hypertrophic  rhinitis ;  others  regard  it  as  occasionally  being  caused  by 
that  form  of  catarrh.  Still  others  regard  it  as  an  entirely  independent 
affection,  in  no  way  connected  with  that  disease.  Certainly  we  may 
conclude  that  its  etiology  is  obscure,  and,  while  the  weight  of  evidence 
is  in  favor  of  its  being  a  later  stage  of  the  hypertrophic  variety  of 
chronic  catarrh,  there  may  be  constitutional  conditions  which  produce 
it  or  it  may  possibly  result  occasionally  from  unnoted  injuries. 

Hyperplasia  of  connective  tissue  in  other  parts  of  the  body  usually 
results  in  atrophy  of  parenchymatous  elements  both  from  its  weight 
and  from  the  pressure  it  exerts  in  contracting.  So  in  the  Schneiderian 
membrane  this  pressure  from  hypertrophied  tissue  is  exerted  to  the 
destruction  of  the  abundant  glandular  tissue.     The  surface  becomes 


5/6  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

dry  and  covered  with  thick  crusts,  whicli  again  tend  to  bring  about  the 
same  result  from  their  pressure  upon  the  epitheHum  and  underlying 
parts.  Not  only  the  mucous  and  submucous  tissues,  but  the  turbinated 
bones  themselves,  are  partially  absorbed  from  the  weight  of  inspissated 
secretions  and  the  weight  and  contraction  of  connective  and  elastic 
tissue.  All  this  makes  unusually  wide  nasal  chambers,  so  that  at 
times  the  posterior  wall  of  the  pharynx  may  be  viewed  from  the  ante- 
rior nares.  When  the  hardened  secretions  and  crusts  are  removed, 
together  with  the  muco-purulent  and  often  bloody  secretions  that  lie 
underneath  them,  the  membrane  is  hyperemic  at  first,  but  soon  may 
look  pink  and  almost  healthy  or  even  almost  colorless.  If  no  crusts 
are  present,  it  has  a  glazed  appearance.  Crusts  are  more  commonly 
adherent  toward  the  anterior  nares  than  at  the  posterior,  and  may 
be  so  large  or  abundant  as  to  stretch  across  or  block  the  nasal  pas- 
sages, causing  temporary  occlusion  and  interfering  with  nasal  respira- 
tion. 

Symptoms. — There  are  usually  discomfort  and  itching  and  an  inclina- 
tion to  remove  the  crusts,  even  forcibly.  Erosions,  ulcerations,  and 
epistaxis  are  therefore  not  uncommon,  and  perforation  of  the  septum 
has  resulted  from  such  causes  and  treatment.  The  most  distinctive 
feature  of  this  disease,  however,  one  so  common  as  to  characterize  it, 
is  the  fetor  almost  constantly  present.  This  arises  from  the  decompo- 
sition of  the  secretions  retained  under  the  crusts  and  within  the  blocked 
meatuses. 

Diagnosis  is  easy  from  the  symptoms. 

Prognosis  as  to  recovery  must  be  guardedly  given,  for  it  is  a  most 
obstinate  disease  to  cure. 

Treatment  is  cleansing,  disinfecting,  and  stimulating.  Cleansing  can 
generally  be  effected  by  persistent  spraying  and  douching.  Occasion- 
ally, however,  mechanical  interference  is  necessary.  The  surgeon,  using 
gentle  force,  removes  with  a  probe  adherent  scales  and  crusts,  cleansing 
any  underlying  ulcers  and  erosions,  removing  all  muco-purulent  secre- 
tions. At  all  events,  after  thorough  cleansing  disinfectant  sprays  and 
douches  must  be  used  to  remove  the  fetor.  Their  name  is  legion — 
boracic  acid,  a  weak  solution  of  carbolic  acid,  iodin,  permanganate  of 
potash,  resorcin,  chlorid  of  ammonia,  and  salicylate  of  soda.  Powders 
are  often  used,  among  which  iodoform  perhaps  stands  first.  Disin- 
fectant sprays  should  be  followed  by  stimulation.  For  this  purpose 
cotton  tampons  are  used,  either  dry  or  moistened  with  glycerin  or 
other  stimulant.  They  exclude  germs  and  air  and  prevent  the  forma- 
tion of  crusts,  and  by  their  use  a  more  natural  condition  of  the  mucous 
membrane  is  maintained.  Such  treatment  is  certainly  more  rational 
than  the  application  of  astringents  to  a  surface  already  deficient  in  reac- 
tion, or  than  caustics  and  scarifications  on  a  surface  already  depleted. 

O^ena  is  a  term  rather  loosely  used  to  describe  either  a  symptom 
or  a  disease  according  as  the  author  means  only  the  fetor  which  arises 
from  a  diseased  condition  or  the  disease  which  gives  origin  to  the  fetor. 
Some  waiters  employ  it  to  include  also  all  fetid  ulceration  due  to  any 
disease  whatever,  while  others  restrict  its  meaning  to  where  it  becomes 
merely  a  synonym  for  atrophic  nasal  catarrh,  otherwise  known  as  fetid 
nasal  catarrh  or  fetid  rhinitis ;  and  this  is  probably  the  signification 


INJURIES  AND  DISEASES   OF  THE  RESPIRATORY  SYSTEM.    577 

more  commonly  given  it,  although  almost  as  frequently  it  is  used  to 
mean  only  an  odor. 

The  fetid  odor  arising  from  caries  of  bone  or  malignant  growths  or 
a  decaying  foreign  body  differs  from  that  usually  termed  ozena,  as  it 
accompanies  atrophic  nasal  catarrh,  yet  ozena  is  sometimes  present 
when  there  is  no  atrophic  rhinitis.  It  is  then  supposed  to  be  due  to  a 
similar  condition  existing  within  the  sinuses.  In  any  case,  the  fetor  is 
believed  to  be  due  to  the  decomposition  of  retained  secretions.  Unlike 
fetors  arising  from  decayed  bone,  it  temporarily  disappears  after  thorough 
cleansing  and  spraying. 

Giving  to  the  term  its  narrower  meaning,  the  symptoms  and  treat- 
ment are  the  same  as  for  atrophic  nasal  catarrh.  If  it  includes  all  fetid 
ulceration,  then  the  treatment  is  that  of  the  disease  giving  rise  to  it. 

Diphtheritic  and  Membranous  Rhinitis. — Should  the  micro- 
organisms of  diphtheria  first  find  lodgement  on  an  abrasion  of  the 
Schneiderian  membrane,  there  is  no  reason  why  a  true  diphtheritic  mem- 
brane should  not  be  developed  there  as  well  as  in  the  throat.  Some- 
times the  diphtheritic  membrane  passes  from  the  pharynx  into  the  pos- 
terior nares.  More  commonly,  however,  an  abundant  sero-fibrinous 
exudation,  caused  by  acute  rhinitis,  rough  surgical  treatment,  or  an 
injury,  deposits  a  false  membrane,  which  may  be  quickly  diagnosed 
from  true  diphtheria  by  the  fact  that  it  is  easily,  removed  without 
hemorrhage.  There  may  be  some  fever,  but  constitutional  .symptoms 
are  less  marked  than  in  diphtheria.  It  should  be  treated  as  an  ordinary 
acute  rhinitis,  with  more  than  ordinary  attention  to  the  removal  of  the 
exudation  and  disinfection  of  the  nasal  passages. 

Purulent  rhinitis  is,  as  a  rule,  due  to  gonorrheal  infection ;  in  the 
case  of  the  infant  it  results  from  contact  with  the  maternal  secretions, 
in  the  case  of  the  adult  from  auto-infection.  Other  causes  are  possible, 
such  as  injuries,  the  presence  of  foreign  bodies,  the  exanthemata,  and 
incipient  ozena.  The  exact  character  of  the  discharge  may  perhaps  be 
determined  by  microscopic  examination. 

Treatment  resolves  itself  into  thorough  cleansing  by  spraying, 
douching,  syringing,  disinfection,  and  the  application  of  astringents. 

Diseases   and    Injuries   of  the   Septum. 

Most  of  the  affections  of  the  nose  already  treated  of  belong  to  the 
septum  in  common  with  the  parts  covered  with  the  Schneiderian  mem- 
brane. But  there  are  certain  lesions  (to  which  it  alone  is  subject) 
dependent  upon  its  anatomical  character  and  position. 

Of  such  lesions  deviation  of  the  septum,  either  congenital  or 
acquired,  is  certainly  the  most  noticeable,  and,  considering  the  long 
train  of  evils  to  which  it  may  give  rise,  the  most  important. 

A  perfectly  normal  septum,  being  on  the  median  line  of  the  body, 
should  divide  the  entire  nasal  cavity  into  two  .symmetrical  halves.  Any 
departure  from  such  a  position  is  termed  a  deviation.  It  may  be  of  all 
degrees,  from  the  merest  inclination  to  one  side  or  the  other,  to  a  single 
or  double  bend  in  the  septum,  either  horizontal,  vertical,  or  both, 
sufficient  to  completely  occlude  the  nostril  and  exert  considerable 
pressure  upon  its  outer  wall.  One  lateral  curve  constitutes,  as  a  rule, 
37 


578  SURGICAL    DIAGXOSIS  AND    TKEATMENT. 

the  deviation,  but  there  may  be  two,  giving  a  sigmoid  curve  to  the 
deviation.  Quite  naturally,  from  its  greater  flexibility,  more  and  greater 
deflections  occur  in  the  cartilaginous  portion  of  the  septum  than  in  the 
bony  part,  and  cjuite  frequently,  when  the  deviation  is  the  result  of 
traumatism,  it  occurs  at  the  junction  of  bone  and  cartilage.  Only  the 
perpendicular  plate  of  the  ethmoid  may  be  warped  or  the  vomer  alone, 
and  finally  the  septum  as  a  whole,  including  bony  parts  and  nasal 
cartilages,  may  curve  toward  one  side.  As  much  as  one  nostril  is 
occluded  by  the  distorted  septum  is  the  other  enlarged  as  a  general 
rule,  but  in  addition  to  the  occlusion  caused  by  the  bulging  on  the 
affected  side  there  is  often  hypertrophy  of  the  turbinated  bones.  At 
the  sutures  of  the  various  parts  there  is  sometimes  an  unusual  degree 
of  thickening,  virtually  an  exostosis  extending  antero-posteriorly. 
This  gives  the  effect  in  one  nostril  of  a  deviation  both  in  appearance 
and  results.  It  may  also  be  bilateral.  There  may  be  quite  an  exten- 
sive deviation  of  the  septum  without  any  appearance  of  external 
asymmetry.  At  times  the  nose  is  badly  twisted  from  its  normal  con- 
tour. Much  attention  has  been  given  in  recent  years  to  the  deviated 
septum,  and  study  of  skulls  has  established  the  fact  that  symmetry  of 
the  septum  is  the  exception,  and  not  the  rule.  While  there  is  not 
perfect  agreement  in  the  conclusions  reached,  there  is  substantial 
unanimity  in  placing  the  proportion  of  asymmetrical  septa  at  about  75 
per  cent. 

In  many  cases,  at  least,  such  statistics  have  referred  to  the  bony 
septum  alone.  Hence,  certainly  the  conclusion  is  a  safe  one  that  dur- 
ing life  anterior  rhinoscopy  would  reveal  a  much  larger  percentage, 
owing  to  the  greater  readiness  of  the  cartilage  to  yield  to  pressure. 
Dr.  Hegman  places  it  as  high  as  99  per  cent,  of  all  persons  examined. 
Deviation  of  the  septum  may  be  congenital,  may  occur  suddenly  from 
traumatism,  or  may  result  from  causes  that  act  more  slowly  and  con- 
stantly. There  is  no  agreement  of  authorities  as  to  the  causes  of 
deviated  septum  of  the  last  sort  mentioned.  Should  it  happen,  for 
any  reason,  that  the  bony  walls  between  which  the  septum  is  placed 
are  of  unequal  thickness  and  resistance,  it  would  naturally  be  affected 
by  such  pressure  and  yield  somewhat,  moving  in  the  direction  of  the 
least  resistance.  Since  the  deviation  is  more  commonly  toward  the  left, 
some  find  an  explanation  of  the  condition  in  the  fact  of  wiping  and 
blowing  the  organ  most  frequently  with  the  right  hand.  Foreign 
bodies  may  have  their  influence  in  determining  it  to  one  side  or  the 
other ;  so  also  unilateral  new  growths.  Some  authors  deny  that  it  is 
ever  congenital.  But  it  is  a  well-established  anatomical  fact  that  there 
is  a  lack  of  perfect  symmetry  in  many  skulls.  As  the  body  develops 
some  cause  or  other,  either  forgotten  or  totally  obscure  and  inappre- 
ciable, determines  a  greater  development  on  one  side  than  on  the  other. 
It  is  certainly  to  be  expected  that  the  septum  will  be  exposed  to  its 
share  of  all  such  untraceable  influences. 

Symptoms. — If  the  deviation  is  only  slight  and  tends  to  remain  so, 
there  are  no  diagnostic  symptoms.  If  it  encroaches  to  any  great  extent 
upon  the  nostril,  we  have  all  the  symptoms  of  occlusion  that  are  pro- 
duced by  any  other  cause.  Most  important  of  all,  respiration  is  inter- 
fered with.     Secretions  are  retained,  rhinitis  is  set  up.     Pressure  on  the 


INJURIES  AND  DISEASES   OF  THE   RESPIRATORY  SYSTEM.    579 

turbinated  bodies  and  the  overlying  mucous  membrane  causes  them  to 
atrophy,  and  the  result  is  atrophic  rhinitis. 

The  usual  complications  and  seqiielcB  of  rhinitis  may  be  present  in 
their  turn,  together  with  headaches  and  reflex  symptoms. 

Diagnosis  is  easy  by  comparison  of  one  nostril  with  another,  and 
by  using  the  probe  to  ascertain  by  the  tactus  eruditus  that  the  pro- 
tuberance is  of  bone  and  not  a  new  growth. 

Treatment. — The  object  in  treatment  is.  first,  to  relieve  obstruction, 
and,  second,  to  restore  the  septum  as  nearly  to  an  ideally  normal  posi- 
tion as  possible,  and  thus  preclude  the  possibility  of  recurrent  obstruc- 
tion from  this  cause. 

Much  depends  upon  the  skill  and  ingenuity  of  the  surgeon.  Fur- 
thermore, inasmuch  as  this  branch  of  surgery  is  of  comparatively 
recent  date,  the  profession  do  not  seem,  as  in  many  other  departments 
of  surgery,  tacitly  to  have  settled  upon  one  or  more  operations  as 
practically  superior. 

One  of  the  earliest  proposed  methods  was  that  of  Adanus.  He 
grasped  the  deviated  septum  between  the  blades  of  forceps  and  reduced 
it  to  its  proper  position  by  crushing  and  fracturing.  After  this  pro- 
cedure rather  elaborate  apparatus  was  necessary  in  order  to  maintain 
the  proper  position  until  repair  was  complete — head-bands,  screw-com- 
pressors, plugs,  etc. — and  this  is  the  case  always  where  forcible  com- 
pression is  employed.  If  the  deviation  is  only  slight  and  in  a  young 
subject,  retentive  plugs  or  something  similar  may  serve  a  useful 
purpose. 

Excision,  in  some  way,  of  the  bulging  portion  seems  to  be  the  better 
plan.  This  may  be  done  with  various  instruments,  as  saw,  scissors, 
chisels,  etc.    Even  a  dental  engine  has  been  proposed.    Steele  employs 


Fig.  254. — Steele's  stellate  forceps  for  deflected  septum. 


forceps  (Fig.  254)  by  which  he  cuts  a  stellate  incision  and  also  forces 
the  septum  back  into  position.  He  retains  it  there  by  ivory  or  wooden 
plugs. 

Another  plan  is  to  lift  the  mucous  membrane,  and  sometimes  the 
perichondrium  with  it,  excise  a  portion  of  the  septum,  replace  the 
mucous  membrane,  and  keep  it  in  place  by  a  sponge  until  repair  is 
complete.  Some  operators  by  punch  or  forceps  remove  a  portion  of 
the  septum.  This  leaves  a  perforation  which  heals  possibly  at  the 
edges,  so  far  as  the  mucous  membrane  is  concerned,  but  is  open  to  the 
same  objections  that  apply  to  a  perforation  caused  by  other  means,  and 
if  large  it  may  cause  external  deformity.  Slicing  away  portions  of  the 
deviated  cartilage  has  been  quite  successful,  as  a  number  of  incisions 
made  antero-posteriorly  make  the  cartilage  lose  its  resiliency,  so  that  it 
can  easily  be  retained  in  place  until  it  has  healed. 


580  SURGICAL   DIAGNOSIS  AXD    TREATMENT. 

Steel  pins  are  used,  thrust  through  from  the  outside,  so  pressing 
upon  the  septum  as  to  force  it  into  position.  They  must  be  retained 
for  some  tla\"s. 

Hematomata. — As  the  direct  result  of  traumatism,  especially  when 
the  septum  is  fractured,  separating  the  cartilaginous  part  from  the  bony 
portion,  extrax'asation  of  blood  often  occurs  between  the  cartilage  and 
mucous  membrane.  Having  a  relatively  broad  base,  they  vary  in  size 
from  minute  spots  to  tumors  so  large  as  to  protrude  from  the  nose. 
They  are  of  a  dark-red  or  bluish  color,  usually  with  marked  fluctu- 
ation, although  tension  may  be  so  great  as  to  prevent  it.  If  small  and 
promptly  treated  with  cold  applications,  they  may  be  absorbed.  If 
absorption  does  not  occur,  they  must  be  incised  at  the  most  dependent 
portion.  They  are  usually  bilateral  and  communicate  through  a  per- 
foration, so  that  one  incision  will  empty  both  lobes  of  the  tumor  if 
gentle  pressure  be  applied ;  otherwise,  each  side  must  be  incised.  They 
are  apt  to  degenerate  into  abscesses  unless  promptly  treated,  and  per- 
foration from  them  may  be  so  large  as  never  completely  to  close. 

Abscesses  are  either  acute  or  chronic.  The  acute  abscess  is  gen- 
erall}'  the  immediate  result  of  injury.  It  is  red,  tender,  painful,  bilateral, 
and  fluctuating,  and  often  by  extension  involves  the  lips  and  cheeks 
and  the  internal  parts  of  the  nasal  cavity,  though  the  abscess  proper  is 
situated  anteriorly  on  the  cartilaginous  part  of  the  septum.  Slight  fever 
is  common.  Early  and  free  incision  on  one  or  both  sides  is  the  only 
treatment.  If  delayed,  periostitis  and  perichondritis  are  likely  to  result. 
Perforation  of  the  septum  is  the  common  sequel. 

Chronic  abscesses  are  of  slower  development,  and  the  intensity  of 
all  the  symptoms  is  less  marked ;  indeed,  the  patient  may  not  even  be 
aware  of  their  existence.  They  may  occur  without  known  origin,  yet 
are  usually  caused  by  syphilis.  Prompt  incision  and  constitutional 
treatment    are  the  indications. 

Perforation  of  the  Septum. — The  most  common  cause  of  this 
condition  is  syphilis,  and  formerly  it  was  believed  that  it  was  the  sole 
cause — that,  given  a  case  of  perforated  septum,  it  was  safe  to  assume 
a  previous  history  of  syphilis  even  if  wholly  beyond  the  patient's 
knowledge  or  memory. 

Other  causes  are  now  admitted :  traumatism  resulting  in  blood- 
extravasations  or  abscess  will  indirectly  produce  it. 

Erosions  caused  by  the  continual  removal  of  crusts  upon  the  car- 
tilaginous part  of  the  septum  often  deepen  into  perforations.  A  local- 
ized perichondritis  or  periostitis  may  be  followed  by  it.  Some  believ'e 
that  it  may  be  congenital. 

Usually  the  edges  of  the  perforation  heal  well  and  they  are  of  slight 
importance.  Sometimes  they  are  so  large  and  so  placed  that  a  current 
of  air  produces  a  slight  whistling  as  it  passes  through.  Rhinoplastic 
operations  to  repair  the  deficiency  have  been  tried,  but  have  met  with 
but  little  success. 

Deformities,  Congenital  Malformations,   and    Defects  of  the  Nose. 

As  has  been  seen  in  the  discussion  of  Diseases  and  Injuries  of  the 
Nose,  deformities  of  various  sorts  are  common,  due  to  alterations  in 


INJURIES  AND   DISEASES   OF   THE   RESPIRATORY  SYSTEM.    58 1 

either  the  external  or  internal  parts.  Such  structural  changes  may  be 
the  result  of  accident  or  disease.  By  far  the  greater  number  are  due 
to  destruction  of  tissue  and  to  cicatricial  contraction  following  the 
ravages  of  destructive  diseases.  Among  these  syphilis  stands  first, 
both  in  frequency  of  occurrence  and  rapidity  of  advance. 

To  such  as  are  caused  by  destruction  of  tissue  may  be  added  those 
resulting  from  the  opposite  cause — the  development  of  an  abnormal 
amount  of  tissue,  as  in  elephantiasis  and  rhinoscleroma,  already  de- 
scribed— or,  finally,  those  in  which  the  nose  is  distorted  by  the  presence 
of  neoplasms  within  the  nasal  cavity.  A  good  example  of  the  latter 
class  is  seen  in  the  so-called  "  frog-face  "  associated  with  naso-phar}m- 
geal  polypi. 

Co)ige7iital  malformations  idW  naturally  into  three  groups:  i.  Those 
in  which  a  whole  or  a  part  of  the  organ  has  not  kept  pace  in  develop- 
ment with  other  parts  of  the  body,  and  is  relatively  small  or  asym- 
metrical ;  2.  Those  in  which  development  has  gone  on  more  rapidly 
than  in  other  parts  of  the  body,  making  the  nose  abnormally  large ; 
3.  Those  in  which  there  is  arrested  development,  leaving  gaps  between 
parts  which  are  fully  developed,  perhaps  in  one  direction,  but  have 
failed  to  unite  properly  w^ith  contiguous  parts  in  other  directions. 

Absence  of  the  nose  is  not  unknown,  the  site  of  the  nasal  organ 
being  a  plane  surface,  with  or  without  perforations  for  nostrils.  The 
nose  may  fail  to  develop  in  its  long  axis,  making  it  too  short — a  "  snub 
nose."  The  nostril  may  be  contracted  also  at  birth.  Should  one  side 
of  the  nose  develop  and  the  other  not,  the  organ  then  lacks  symmetry 
and  gives  a  most  peculiar  appearance  to  the  face.  Slight  asymmetr}^ 
of  the  nose  is  not  uncommon,  but  can  scarcely  be  called  congenital. 
Nor  is  it  the  result  of  disease,  but  is  due  to  greater  pressure  on  one 
side  than  on  another  when  the  organ  is  blown  and  wiped. 

Sometimes  a  nose  is  abnormally  large  from  disproportionate  develop- 
ment, and  the  organ  may  even  be  double  or  be  furnished  with  three  nos- 
trils or  with  a  small  outgrowth  at  the  root  or  on  one  side  that  simulates 
a  nose  on  a  small  scale.  Sometimes  one  or  both  nostrils  are  occluded 
by  the  development  of  adventitious  tissue  at  the  opening  or  within  the 
cavity.  Should  this  extra  tissue  remain,  the  result  will  be  not  an 
abnormally  large  nose,  but  an  undersized  one,  because  the  nostril, 
being  shut  from  the  air,  contrar}^  to  Nature's  designs,  suffers  from 
diminished  nutrition.  Sometimes  the  nasal  cartilages  do  not  unite  in  the 
middle  line,  or  the  alae  are  too  much  separated  at  their  bases  from  the 
face,  leaving  clefts  or  fissures.  Such  deficiencies  are  usually  found  in 
connection  with  hare-lip  and  cleft-palate,  being  a  continuation  of  the 
fissure  in  lip  or  palate. 

Plastic  operations  maybe  undertaken  to  close  such  fissures  and  also 
to  correct  some  deformities  that  are  due  to  cicatricial  contraction. 

Outgrowths,  making  abnormally  large  noses  or  double  noses,  may 
sometimes  be  removed.  Rhino-scleroma  and  hypertrophy  have  already 
been  discussed. 

If  the  nose  has  failed  to  develop  from  contracted  or  occluded  nos- 
trils, dilatation  or  removal  of  adx-entitious  tissue  is  indicated. 

When  the  entire  organ  is  lost  by  accident  or  destructive  disease  an 
artificial  nose  may  take  its  place. 


582  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

Rhinoplasty. 

Rhinoplastic  art  has  for  its  object  the  restoration  of  the  whole  or 
such  part  of  the  nose  as  may  be  wanting.  Deficiencies  of  the  nose 
may  be  congenital,  the  result  of  accident  or  of  destructive  ulceration, 
and  they  may  be  limited  to  the  soft  structures,  or  there  may  be  impli- 
cation of  bony  tissue  as  well.  Thus,  rhinoplasty,  varying  from  a  trifling 
operation  where  a  slight  fissure  is  filled  in  to  where  the  entire  organ  is  con- 
structed, naturally  divides  itself  into  partial  and  complete  rhinoplasty. 

Whatever  the  operation,  it  should  not  be  undertaken  until  all  dis- 
eased and  necrosed  tissue  is  removed,  nor  until  the  destructive  process 
is  clearly  at  an  end  without  prospect  of  renewal.  Tissues  to  repair 
deficiencies  arc  taken  from  the  cheek  or  lip,  the  forehead  or  the  arm. 

If  the  restorative  process  is  to  be  only  slight  and  on  the  side  of  the 
nose,  it  is  best  generally  to  take  the  graft  of  skin  from  the  cheek ;  if  it 
is  of  considerable  extent,  from  the  forehead.  If  a  new  columna  nasi 
is  to  be  formed,  a  graft  is  cut  from  the  median  portion  of  the  upper  lip, 
and  the  lip  is  closed  and  dressed  exactly  as  in  hare-lip.  Such  a  flap 
may  be  made  to  do  further  duty  in  forming  the  ridge  of  a  nose  by  dis- 
secting the  mucous  membrane  of  the  lip  away  from  the  skin,  and 
extending  it  as  the  prolongation  of  the  skin  up  to  the  root  of  the  nose, 
the  mucous  membrane  in  its  unwonted  situation  taking  upon  itself  the 
characteristics  of  cutaneous  tissue.  When  this  is  done  the  sides  of  the 
nose  may  be  supplied  by  flaps  from  the  cheeks.  Something  might 
depend  upon  the  fulness  of  the  upper  lip  and  cheek  in  deciding  upon 
such  an  operation.  Commonly,  however,  if  a  considerable  portion  of 
the  nose  is  to  be  restored,  the  forehead  furnishes  the  desired  graft.  If 
only  a  small  portion  of  the  lower  part  of  the  ala  be  wanting,  the  upper 
part  of  the  nose  itself  may  be  made  to  furnish  the  skin  for  transplanta- 
tion. Fistulous  openings,  the  result  of  scarlet  fever  and  other  exan- 
themata, are  repaired  usually  with  flaps  from  the  cheeks. 

In  all  these  operations  some  pattern  of  the  desired  graft  must  be 
traced  out  on  forehead  or  cheek,  allowance  being  made  for  retraction 
of  the  skin.  A  pedicle  must  be  left  to  ensure  a  blood-supply,  and  care 
must  be  taken  not  to  twist  the  pedicle  too  severely,  since  that  alone, 
by  cutting  off  the  circulation,  will  frustrate  an  otherwise  successful  ope- 
ration. When  the  engrafted  tissue  has  grown  firmly  in  its  new  position 
the  pedicle  is  severed.  Some  trimming  and  adjustment  of  edges  may 
then  be  necessary,  also  a  suture  or  two  to  complete  the  operation. 

A  nose  too  short  has  been  improved  by  cutting  transversely  across 
it,  drawing  it  down  to  a  suitable  position,  where  it  is  held  in  place  by 
pins,  and  filling  in  the  triangular  space  with  tissue  cut  from  each  cheek 
and  meeting  in  the  median  line  on  the  ridge  of  the  nose.  The  bare 
mention  of  such  an  operation  suggests  the  thought  that  the  opposite 
procedure,  removal  of  a  similar  shaped  portion  of  tissue  in  a  too  pro- 
tuberant proboscis,  might  afford  an  opportunity  for  a  more  brilliantly 
successful  operation. 

Some  of  the  earliest  attempts  at  plastic  surgery  were  made  in  the 
effort  to  construct  an  entire  nose,  and  both  of  the  methods  now  most 
in  vogue  are  with  more  or  less  modifications  those  that  were  employed 
when  other  operations  of  modern  surgery  were  hardly  dreamed  of 


INJURIES  AND  DISEASES   OF  THE   RESPIRATORY  SYSTEM    583 

Whichever  is  selected,  a  definite  idea  must  be  obtained  as  to  the 
amount  and  size  of  tissue  needed  to  construct  the  organ.  Generally 
upon  the  face  of  the  patient  a  form  is  made  of  wax  or  other  plastic 
material.  From  this  a  pattern  is  made  pyriform  in  outline,  from  which 
the  graft  is  traced  out,  allowance  being  made  for  the  retraction  of  the 
skin.     It  is  usual  to  allow  one-third  for  retraction. 

Tagliacozzi  was  a  learned  Italian  surgeon  of  the  latter  part  of  the 
sixteenth  centur}-^  and  just  at  the  close  of  the  century  he  published  a 
description  of  the  operation  that  now  bears  his  name — the  Tagliacotian. 
He  cut  from  the  upper  arm  a  skin-graft  of  the  required  size  and  shape, 
leaving  it  attached  by  a  pedicle.  After  this  was  done  he  left  it  for  about 
two  weeks,  that  it  might  thicken  and  granulate.  Then  he  freshened  the 
stump  of  the  nose  to  which  it  was  to  be  attached,  adjusted  the  flap,  and 
fastened  it  with  sutures.  Since  absolute  immobility  of  the  arm  must 
be  maintained  for  about  two  weeks,  numerous  slings,  bandages,  and 
appliances  were  necessary  to  keep  it  immovably  fixed.  At  the  end  of 
that  time  the  pedicle  was  severed,  the  arm  released,  and  a  columna  nasi 
fashioned  from  the  upper  lip.     Modern  operators  use  a  flap  from  the 


4  ^  "^^ 


Fig.  255. — Indian  method  of  rhinoplasty  (Prince). 


forearm  instead  of  the  upper  arm,  and,  though  this  operation  possesses 
the  advantage  of  not  disfiguring  the  forehead,  it  is  exceedingly  difficult 
to  secure  absolute  immobility,  and  then  very  tiresome  to  maintain  it  for 
the  necessary  length  of  time. 

The  other  method,  known  as  the  Indian  because  originally  practised 
in  India,  is  now  more  generally  employed  than  any  other.  The  size 
and  shape  of  the  flap  are  determined  as  in  the  other  operation. 
Beginning  at  the  root  of  the  nose,  the  narrow  end  widens  into  the 
broad  end  of  the  pyriform  flap,  either  in  the  middle  or  on  one  side  of 
the  forehead  (Fig.  255).  If  made  to  one  side  of  the  median  line,  the 
operation  gives  a  fairer  promise  of  success,  because  there  necessarily 
is  less  rotation  of  the  flap  upon  its  pedicle. 

All  the  soft  tissues  are  incised  down  to  the  periosteum  of  the  frontal 
bone.  Some  authorities  recommend  that  the  periosteum  also  be  in- 
cluded in  the  tissues,  and  even  some  fragments  of  the  outer  table  of 
the  frontal  bone,  so  that  bone  may  be  developed  from  the  osteoblasts, 
and  a  better  shape  for  the  nose  be  ensured.  The  stump  is  then  fresh- 
ened and  bevelled,  to  be  united  with  the  properly  bevelled  edge  of  the 


584  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

flap,  or  the  skin  may  be  slit  and  the  flap,  after  being  bevelled  on  its 
outer  surface,  may  be  inserted  into  this  groove.  Numerous  fine  sutures 
are  employed  to  hold  the  flap  in  place  ;  the  ala^  and  nostrils  are  shaped 
and  stitched,  and  a  septum  made  by  drawing  down  the  inner  part  of 
the  flap  and  stitching  it  to  the  upper  lip.  The  nostrils  are  kept  open 
with  tubes  or  plugs,  and  the  nose  supported  with  dressings  which  are 
kept  on  for  several  days.  The  patient  is  confined  to  bed,  and  the  tem- 
perature of  the  room  kept  warm  and  even.  When  union  is  firm  the 
pedicle  is  severed,  the  edges  trimmed,  and  final  adjustment  made  of  the 
flap  at  the  root  of  the  nose.  The  columna  nasi  is  made  from  the  upper 
lip,  as  before  described.  Some  operators  by  prolonging  the  original 
flap  at  the  middle  of  the  base  provide  a  covering  for  the  columna 
nasi.  The  objection  to  this  plan  is  the  unnecessarily  long  forehead 
incision. 

The  forehead  wound  is  drawn  together  as  much  as  possible,  and 
left  to  heal  by  granulation. 

Too  much  allowance  should  not  be  made  for  shrinkage,  or  the  nose 
may  be  so  extraordinary  in  size  as  to  constitute  a  deformity  almost  as  bad 
as  the  one  it  was  intended  to  remedy.  Various  surgeons  have  made 
modifications  of  these  operations,  for  the  details  of  which  the  student  is 
referred  to  special  works. 

If  there  are  objections  or  contraindications  to  operations  of  this 
sort,  artificial  noses,  held  in  position  by  spectacles,  offer  a  very  credit- 
able substitute  for  Nature's  handiwork. 

Rhinoscopy. 

Rhinoscopy  as  now  practised  owes  its  existence  to  the  discovery  of 
laryngoscopy,  for  posterior  rhinoscopy  employs  practically  the  same 
instruments  and  means  as  does  the  sister  art.  Anterior  rhinoscopy  was 
no  doubt  practised  in  the  surgery  of  very  early  times,  but  its  import- 
ance, considered  alone,  has  been  greatly  enhanced  by  the  ability  to 
view  also  the  naso-pharynx. 

Only  a  few  simple  instruments  are  really  necessary  for  the  practice 
of  rhinoscopy.  Of  prime  importance  is  some  good  source  of  illumi- 
nation. This  may  be  a  simple  oil  lamp  or  a  gas  or  an  electric  light 
with  complicated  fixtures.  A  student  lamp  with  a  metallic  chimney  in 
which  is  adjusted  a  plano-convex  lens  for  condensing  the  rays  of  light, 
if  that  is  necessary  or  desirable,  is  a  very  good  light. 

A  good  gas-light  in  suitable  position  with  reference  to  that  of  the 
patient  will  do  very  well.  Such  a  light,  so  attached  to  a  bracket  that 
it  will  move  in  all  planes,  with  the  chimney  and  lens  for  condensing, 
constitutes  a  very  excellent  source  of  illumination. 

A  concave  forehead  reflector  with  a  central  perforation,  having  a 
ball  and  socket  on  the  rim,  adjusted  either  by  a  band  or  a  spectacle 
frame,  a  nasal  speculum  and  a  nasal  retractor  for  anterior  rhinoscopy, 
a  small-sized  laryngoscopic  mirror,  and  a  tongue-depressor  for  poste- 
rior rhinoscopy,  are  all  the  instruments  needed. 

In  anterior  rhinoscopy  an  ear-speculum  of  small  size  and  a  little 
larger  than  usual  may  be  employed.  Thudicum's  speculum,  a  bivalve 
instrument,  is  very  useful  (Fig.  256).    Self-retaining  wire  dilators  are  of 


INJURIES  AND  DISEASES   OF   THE   RESPIRATORY  SYSTEM.    585 


Fig.  256. — Thudicum's  nasal  speculum. 


great  convenience  and  cover  the  minimum  amount  of  the  .surfaces  to  be 
examined.  Those  known  as  Frankel's  and  some  varieties  invented  and 
used  by  Prosser  James  are  the  best. 
Special  rhinoscopic  mirrors  are  not 
necessary ;  the  small  sizes  of  larj'n- 
goscopic  mirrors  are  generally  used 
with  the  handle  bent  to  an  angle  of 
about  105°. 

Anterior  Rhinoscopy. — For  the 
practice  of  anterior  rhinoscopy  the 
patient  is  seated  directly  in  front  of  the 
surgeon  in  an  upright  position,  the 
head  thrown  slightly  backward.  The 
light  is  placed  so  as  to  come  over  the 
right  shoulder  of  the  patient.  The 
rays  are  focussed  upon  the  forehead 
mirror,  and  thence  thrown  into  the 
nasal  fossa,  which  it  is  thus  possible  to 
explore  completely  from  roof  to  floor  and  from  septum  to  side.  The 
middle  and  inferior  turbinated  bodies,  the  middle  and  inferior  meatus, 
come  plainly  into  view ;  the  superior  turbinated  body  is  rarely  or  never 
seen.  If  the  nostril  is  unusually  spacious,  it  may  be  possible  to  see 
the  posterior  wall  of  the  pharynx. 

Not  all  portions  of  the  nasal  mucous  membrane  are  of  the  same 
color.  The  middle  turbinated  body  is  of  a  pale  color,  the  septum  is 
darker,  and  the  inferior  body  the  deepest  red  of  all. 

Cocain  should  ordinarily  be  applied  in  a  first  examination.  After 
tolerance  has  been  established  it  may  be  less  necessary.  The  lower 
turbinated  body  has  much  erectile  tissue,  which  on  irritation  is  apt  to 
become  distended  and  occlude  the  passage.  Application  of  cocain  pre- 
vents this,  and  reduces  the  abnormal  sensitiveness  of  inflamed  parts 
of  the  surface. 

Posterior  Rhinoscopy. — In  posterior  rhinoscopy  the  position  of 
the  patient  and  of  the  light  are  the  same  as  in  anterior  rhinoscopy, 
but  here  the  light  is  thrown  into  the  mouth  and  concentrated  upon  a 
mirror  at  the  back  of  the  throat,  so  that  the  observer  does  not  get  a 
direct  view  of  the  parts  he  is  examining,  as  before,  but  an  image  only. 
The  mouth  must  be  opened  widely,  and  the  tongue  well  depressed  on 
the  floor  of  the  mouth.  The  mirror  is  warmed  to  prevent  condensation 
of  vapor  upon  it,  and,  introduced  at  the  corner  of  the  mouth,  is  carried 
up  behind  the  velum,  and  should  be  brought  to  a  standstill  midway 
between  that  and  the  posterior  pharyngeal  wall. 

Certain  difficulties  present  themselves  here  in  some  cases.  The 
hard  palate  may  be  prolonged  so  far  backward  that  there  is  scant  room 
between  it  and  the  pharyngeal  wall,  and  this  may  be  so  pronounced 
that  it  is  not  possible  to  obtain  an  image  at  all.  Adenoid  vegetations 
may  present  themselves  in  the  way.  These  have  to  be  removed  before 
the  examination  is  practicable.  A  long  soft  palate  may  hang  so  low  as 
to  obscure  the  image.  In  this  case  it  must  be  held  aside  by  a  retractor 
or  palate  hook ;  or  a  ligature  may  be  passed  around  it  and  fastened  to 
a  tooth,  thus  giving  freedom  to  the  surgeon's  hand.     A  tape  may  also 


586 


SURGICAL   DIAGNOSIS  AXD    TREATMENT. 


be  passed  throuL:^h  the  nostrils  and  brought  out  of  the  mouth,  Hfting 
the  pahite  out  of  the  way.  The  tape  is  generally  carried  over  and  tied 
behind  the  ears.  Another  obstacle  to  examination  is  that  the  patient  as 
soon  as  he  opens  his  mouth  begins  oral  respiration,  and  the  entering 
current  of  air  carries  the  uvula  tightly  against  the  pharygneal  wall. 
This  can  quickly  be  corrected  if  the  patient  will,  even  with  the  mouth 
open,  acquire  the  ability  to  breathe  through  the  nose.  He  may  be 
directed  to  place  his  hand  tightly  over  the  widely-open  mouth.  He 
will  then  be  forced  to  nasal  respiration.  Removing  the  hand,  he  can 
easily  continue  the  same  mode  of  breathing. 

The  rays  of  light  from  the  reflector  must  fall  upon  the  mirror  in  the 
fauces  in  such  a  manner  that  they  will  be  reflected  from  it  upon  the 
posterior  nares.  The  mirror  will  thus  receive  the  "  rhinoscopic  image." 
Only  rarely,  however,  will  a  complete  image  be  reflected  upon  it.  The 
mirror  is  held  so  as  to  examine  first  one  side,  and  then  the  other,  and 
the  mind  combines  the  two  halves  so  as  to  make  the  perfect  picture. 

At  first  the  observer  will  be  able  to  make  out  little,  but  patience  and 
care  will  soon  make  the  different  parts  stand  out  clearly  (Fig.  257). 


Fig.  257. — Representation  of  posterior  rhinoscopic  image. 

When  the  mirror  is  finally  adjusted  at  the  proper  angle,  about  130 
degrees  with  the  horizon,  first  the  posterior  surface  of  the  uvula,  then 
that  of  the  velum,  come  into  view.  The  velum  arches  up  in  the  field  of 
vision  so  as  to  always  obscure  a  part  of  the  lower  posterior  nares. 
The  septum  nasi  is  most  prominent,  and  soon  asserts  itself  as  the  land- 
mark to  which  the  other  parts  are  instinctively  referred.  It  is  narrow, 
glistening,  and  pale  below,  but  widens  out  into  the  pharyngeal  vault, 
deepening  in  color  as  it  increases  in  width,  though  the  darker  color  is 
partly  due  to  the  fact  that  above  it  is  less  brilliantly  illuminated.  On 
either  side  are  two  somewhat  oval  spaces,  much  darker  in  color  than 
the  septum,  since  they  are  hollow  or  receding — the  choanae  or  posterior 
nares. 

Stretching  across  from  the  external  side  of  each  are  three  bulbous 
structures,  the  turbinated  bodies.  The  middle  one  is  the  most  promi- 
nent, really  overshadowing  the  other  two.     The  superior  turbinated 


INJURIES  AND   DISEASES   OF   THE   RESPIRATORY  SYSTEM.    587 


bodies  are  small,  of  triangular  shape,  pointing  downward  and  inward, 
and,  indeed,  are  sometimes  scarcely  visible,  being  overlapped  by  the 
middle  ones.  The  inferior  turbinated  bodies  fill  in  the  lower  outer  angle 
of  the  space  external  to  the  septum  and  overlie  the  lower  part  of  the 
middle  body.  Owing  to  the  arch  of  the  velum,  their  lower  part  is 
rarely  visible,  though  here,  as  elsewhere,  there  is  great  variety  in  the 
configuration  of  the  parts.  This  shape  of  the  velum  prevents  the 
inferior  meatus  from  appearing  in  the  rhinoscopic  image.  The  middle 
one  comes  out  distinctly  as  a  depression  between  the  middle  and  infe- 
rior bodies  toward  the  outer  boundary  of  the  space.  The  superior 
meatus  looks  like  a  line  above  the  middle  turbinated  body.  The  orifice 
of  the  Eustachian  tube  presents  on  each  side  opposite  the  upper  part 
of  the  inferior  turbinated  body.  It  is  a  depression  situated  on  a  smooth 
rounded  projection,  and  lies  in  a  different  plane  from  the  parts  just  de- 
scribed. It  is  scarcely  necessary  to  say  that  for  the  successful  practice 
of  rhinoscopy  a  thorough  knowledge  of  the  normal  parts  is  indis- 
pensable. 

A  great  variety  of  instruments  and  also  of  medicaments  are  em- 
ployed in  the  treatment  of  diseases  of  the  nasal  passages.  Most  of 
these  have  been  discussed  in  the  treatment  of  nasal  diseases,  and  men- 
tion has  also  been  made  of  the  different  methods  both  of  cleansing  and 
of  treatment ;  the  student  is  referred  to  complete  works  on  rhinal 
therapeutics  for  more  detailed  information. 

The  douche,  both  in  the  profession  and  among  the  laity,  is  the  most 
widely  known  of  any  method  both  for  cleansing  and  for  treating  the 
nasal  passages. 

The  simplest  arrangement  is  that  of  a  reservoir  of  some  sort,  a  cup, 
a  bottle,  or  a  small  fountain  syringe,  to  which  is  attached  rubber  tubing 
ending  in  a  nose-piece.  The  nose-piece  is  passed  into  one  nostril,  the 
patient  bending  slightly  over  a  basin.  He  must  resist  the  inclination  to 
swallow  as  the  liquid  strikes  the  pharynx,  so  that  it  will  not  pass  into 
the  Eustachian  orifice,  and  im- 
mediately the  stream  will  pass 
into  the  posterior  nares  of  the 
other  nostril. 

Many  surgeons  prefer,  in- 
stead of  the  douche,  a  coarse 
spray.  There  are  many  varieties 
of  nasal  spray-producers,  of 
which  Leffert's  is  one  of  the 
best  (Fig.  258). 

Syringes  are  useful  for  re- 
moving crusts  and  inspissated 
secretions.  A  common  bulb- 
syringe,  fitted  with  suitable 
nasal  tubes,  may  be  used,  al- 
though syringes  especially  for 
the     nose     are     manufactured. 

For  the  anterior  nares  a  straight  hard  tube  is  used  or  the  aurist's 
syringe,  but  for  the  posterior  nares  a  tube  curved  at  the  end  so  as  to 
enter  and  fit  into  the  posterior  opening  is  necessary. 


588  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

Compressed  air-atomizers  of  complicated  structure  are  a  desideratum 
in  the  treatment  of  obstinate  chronic  cases,  especially  those  of  syphilitic 
origin. 

Insufflators  are  of  common  use,  and  apply  a  powder  instead  of  a 
liquid  to  the  nasal  mucous   membrane. 

Bougies  of  soluble  materials  are  often  used  in  treatment  of  the  nasal 
passages.  Dilators,  either  solid  or  hollow,  of  soft  or  hard  material,  are 
a  necessary  part  of  the  outfit  of  those  who  treat  diseases  of  the  nasal 
passages. 

The  medicaments  used  resolve  themselves  into  astringents,  stim- 
ulants, cleansing  solutions,  antiseptics,  and  caustics,  and  their  name  is 
legion,  though  they  are  the  same  as  are  used  to  accomplish  the  same 
results  in  other  parts  of  the  body. 

II.    DISEASES  AND  INJURIES  OF  THE  ACCESSORY  SINUSES  OF  THE 

NOSE. 

The  Antrum  of  Highmore  or  the  Maxillary  Sinus. — In- 
juries.— "  This  cavity  hollowed  out  of  the  body  of  the  maxillary  bone  " 
is  more  open  to  injury  than  any  other  accessory  sinus  of  the  nose, 
both  from  its  exposed  position  at  the  most  prominent  portion  of  the 
face,  and  because  its  walls  are  very  thin  and  yield  readily  to  pressure  or 
violence.  A  blow  upon  the  cheek  may  fracture  the  w^alls  of  the 
antrum,  or  it  may  be  penetrated  by  a  weapon  or  by  bullets,  in  wdiich 
case  the  fracture  is  compound. 

If  the  fracture  is  simple  without  depression,  the  pain  and  soreness 
may  quickly  subside,  giving  no  marked  symptom  of  inflammation  and 
without  permanent  injury.  If  the  fracture  is  comminuted,  depression 
is  likely  to  occur.  The  bone  may  be  restored  to  position  by  operative 
interference  either  through  the  nose  or  the  mouth.  It  is  rarely  possi- 
ble for  fractures  of  the  walls  of  the  sinus  to  occur  without  setting  up 
inflammation  of  the  mucous  membrane  lining  the  cavity,  followed  by 
abscess  as  a  rule. 

Foreign  bodies  in  the  antrum  are  usually  either  bullets  or  insects. 
To  these,  as  occurring  rarely,  may  be  added  the  crusts  formed  by  an 
ozena  of  the  antrum,  spicula  of  bone,  portions  of  broken  instruments, 
drainage-tubes,  bits  of  gauze,  etc.  from  former  operations. 

Diseases. — Inflammation  may  be  either  acute  or  chronic. 

Simple  acute  inflaviination  without  abscess  is,  no  doubt,  a  frequent 
occurrence  as  a  complication  of  severe  coryza.  The  symptoms  are 
negative,  however,  unless  the  process,  instead  of  ending  in  steady 
resolution,  goes  on  to  the  acute  purulent  form.  In  this  case  the  ostium 
maxillare  is  temporarily  closed  from  the  congestion  and  inflammation  of 
the  mucous  membrane  in  the  narrow  orifice.  Other  causes  are — trau- 
matism, as  previously  mentioned ;  the  presence  of  polypi  in  the  nose, 
closing  the  ostium  maxillare  (or  of  polypi  within  the  antrum,  effecting 
the  same  thing) ;  or,  more  frequently  than  anything  else,  dental  caries, 
particularly  that  form  in  which  an  alveolar  abscess  infects  the  antrum 
by  extension  from  the  root  of  a  tooth  that  projects  up  into  the  floor 
of  the  antrum.  It  has  been  observed  in  the  case  of  infants  from 
injuries  received  during  labor. 


INJURIES  AND  DISEASES   OF   THE   RESPIRATORY  SYSTEM.    589 

Syuiptonis. — There  may  be  no  physical  signs  of  acute  purulent  in- 
flammation of  the  antrum,  but  in  severe  cases  they  are  usually  present 
in  a  more  or  less  pronounced  degree.  If  there  is  no  outlet  for  the 
pent-up  pus,  then  the  objective  symptoms  are  most  marked  and  the 
subjective  most  painful. 

The  abscess,  even  though  it  is  surrounded  by  bony  walls,  produces 
marked  distortion.  It  may  crowd  the  teeth  downward  until  they  pro- 
ject abnormally  in  the  mouth  ;  it  may  flatten  the  normally  convex 
hard  palate ;  it  may  push  up  the  floor  of  the  orbit  until  the  eyeball 
bulges  forward ;  it  may  crowd  the  adjoining  nasal  wall  until  it  closes 
the  nostril  or  may  cause  marked  enlargement  of  the  cheek  over  the 
malar  bone. 

With  such  signs  fluctuation  is  generally  present,  because  the  bone 
is  much  thinned,  and  eventually,  unless  the  pressure  is  relieved  by 
surgical  interference,  the  abscess  will  burst  at  the  point  of  least  resist- 
ance, either  into  the  nostril  or  the  mouth,  or  very  rarely  through  the 
cheek  or  the  floor  of  the  orbit.  Crepitation  is  frequently  detected  over 
a  thinned  portion  of  bone.  If,  however,  the  ostium  maxillare  is  patent, 
pus  will  be  discharged  into  the  middle  meatus  of  the  nostril  from 
beneath  the  turbinated  bone  on  one  side.  This  may  be  continuous  or 
intermittent,  and  may  increase  or  decrease  in  amount  according  to  the 
position  of  the  head.  When  this  is  the  case,  it  is  frequently  observed 
that  the  color  of  the  discharge  is  ozenic.  When  pus  is  confined  within 
the  antrum  there  are  tenderness  on  pressure,  pain  radiating  in  various 
directions,  and  a  feeling  of  distention  and  distress  in  the  head  generally. 
The  soft  parts  of  the  face  may  be  greatly  swollen.  There  may  be  also 
constitutional  symptoms,  such  as  accompany  the  accumulation  of 
purulent  matter  in  other  parts  of  the  body,  rigors,  sweats,  fever,  and 
severe  headache. 

Diagnosis  is  made  by  the  discharge  of  pus  into  the  middle  meatus 
if  the  opening  into  the  nostril  is  patulous — by  the  physical  signs  and 
constitutional  symptoms  if  it  is  occluded. 

Some  authors  advocate  transillumination  by  means  of  a  small  elec- 
tric lamp  placed  in  the  mouth  as  a  means  of  differential  diagnosis.  It 
will  be  seen,  however,  that  this  would  be  little  more  than  confirmatory 
of  other  symptoms.  The  patient  is  placed  in  a  dark  room,  and  the 
lessened  illumination  of  the  diseased  side  of  the  face  gives  evidence  of 
opacity  in  the  antrum.  Such  opacity  might,  however,  be  due  to  thick- 
ened bony  walls,  to  tumors  or  cysts,  or  to  greater  thickness  of  the 
overlying  tissues  on  the  one  side.  Should  abscess  of  the  antrum  be 
bilateral — a  condition  not  unknown — transillumination  would  be  of  no 
value  unless  it  could  be  demonstrated  that  the  illumination  of  the 
face  was  less  than  in  the  case  of  a  large  number  of  other  people. 
Possibly  the  Rontgen  rays  may,  at  no  distant  time,  become  avail- 
able in  clearing  a  diagnosis  in  such  conditions.  Foreign  bodies, 
cysts,  and  tumors  in  the  antrum  may  present  some  difficulties  to  the 
diagnostician,  but  the  evidences  of  acute  inflammation  under  these  con- 
ditions is,  as  a  rule,  absent,  and  the  cachexia  of  malignant  growths  is 
wanting  in  abscess. 

When  pus  appears  persistently  in  the  nostril  of  an  adult,  it  may  be 
from  any  one  of  the  sinuses.     If  all  signs  of  its  source  are  absent,  the 


590  Si'MG/CAL   D/AGXOS/S  AND    TREATMENT. 

patient  may  be  directed  to  bend  the  head  low,  when  the  discharge  will 
be  increased  if  it  is  from  the  antrum  of  Highmore.  On  resuming  the 
erect  position  it  will,  if  wiped  away,  not  return  at  once.  If  it  comes 
from  the  other  sinuses,  removal  will  not  stop  the  flow.  In  children 
foreign  bodies  in  the  nose  most  commonly  produce  a  unilateral  discharge, 
and  from  anatomical  considerations  young  persons  seldom  suffer  from 
antrum-disease.  If,  after  all  attempts  to  settle  the  question  of  abscess 
of  the  maxillary  sinus,  doubt  still  remains,  an  exploratory  incision  may 
be  made,  preferably  through  the  canine  fossa,  or  the  inferior  meatus, 
where  the  bone  is  so  thin  that  moderate  force  will  effect  an  entrance. 

Trcatuioit. — In  acute  inflammation  of  the  maxillary  sinus  without 
the  formation  of  abscess  antiseptic  and  detergent  washes  in  the  nasal 
chamber,  with  hot  applications,  are  generally  all  that  is  necessary  both 
to  cure  the  existing  condition  and  to  prevent  further  trouble.  On  the 
first  indication  of  the  accumulation  of  pus,  here,  as  elsewhere,  free 
evacuation  is  the  rule.  If  a  carious  tooth  can  be  profitably  spared 
here,  through  its  socket  is  the  ideal  opening,  both  for  ease  of  access 
and  thoroughness  of  drainage,  and  such  a  route  was  formerly  the  only 
one  attempted,  even  if  a  sound  tooth  were  sacrificed.  Now,  however, 
if  no  decayed  tooth  present  itself  for  vicarious  extraction,  an  opening 
is  made,  either  with  probe  or  trocar,  at  the  lower  part  of  the  canine 
fossa  or  near  the  floor  of  the  nostril  in  the  inferior  meatus,  or  in  both 
places,  by  which  drainage  is  more  rapid  and  irrigation  more  thorough. 
If  it  is  suspected  that  the  purulent  inflammation  is  caused  by  a  foreign 
body  or  by  necrosed  bone,  thorough  search  for  such  must  be  made 
with  a  probe,  even  to  the  breaking  down  of  septa  of  bone.  The  re- 
moval of  such  foreign  material  may  make  it  necessary  to  enlarge  the 
opening. 

Chronic  inflainination  of  the  antrum  of  Highmore  may  persist  for 
years.  It  may  run  a  rather  steady  course,  or  a  chronic  condition,  with 
discharges  comparatively  slight  in  amount  and  at  rather  long  intervals, 
may  with  some  regularity  give  way  to  more  acute  exacerbations,  during 
which  both  the  frequency  and  the  amount  of  the  discharge  are  notice- 
ably increased.  In  either  case  there  is  evidence  of  accumulated  secre- 
tion in  the  fact  that  lying  down  or  bending  the  head  to  one  side  or  low 
down  will  increase  the  amount  of  the  discharge.  Pain  is  not  generally 
a  marked  symptom,  though  headache  is  common,  and  there  is  a  depres- 
sion of  spirits  and  a  generally  lowered  tone  to  the  system. 

Constant  discharge  of  pus  over  the  Schneiderian  membrane  is 
believed  by  some  to  cause  nasal  polypi,  and  these,  on  the  other  hand, 
by  occluding  the  opening  into  the  antrum,  may  bring  on  acute  inflam- 
mation, though  by  some  authors  a  form  of  chronic  inflammation  is 
described  in  which  the  outlet  is  occluded. 

Diagnosis  must  rest  upon  the  unilateral  discharge,  usually  fetid, 
from  the  nose ;  and  since  it  is  possible  for  a  discharge  from  the  frontal 
sinus  through  the  fronto-nasal  canal  and  the  ostium  maxillare  to  reach 
the  antrum,  and  also  from  the  ethmoidal  cells  through  the  hiatus  semi- 
lunaris to  reach  the  same  place,  it  is  plain  that  an  absolute  diagnosis 
without  confirmatory  symptoms  is  sometimes  impossible,  for  these  dis- 
charges would  reach  the  nasal  cavity  from  the  antrum,  appearing  under 


INJURIES  AND   DISEASES   OF   THE   RESPIRATORY  SYSTEM.    59 1 

the  middle  turbinated  bone,  and,  nevertheless,  the  mucous  membrane 
of  the  antrum  be  wholly  free  from  the  inflammatory  process. 

Treatment. — Under  the  conditions  last  sketched  treatment  of  the 
antrum  of  Highmore  would  be  utterly  futile.  If,  however,  the  dis- 
charge really  has  its  origin  in  the  sinus,  and  will  not  yield,  as  it  fre- 
quently does,  simply  to  intranasal  douching  with  antiseptic  and  astrin- 
gent lotions,  then  the  antrum  must  be  opened,  cleansed,  and  drained. 
The  choice  as  to  openings  is  to  be  made  as  in  the  case  of  acute  inflam- 
mation. Antiseptic  solutions,  as  boric  acid,  are  then  used  to  cleanse 
the  antrum.  After  exploration  and  removal  of  foreign  substances  or 
necrosed  bone  a  drainage-tube  (either  Myles'  or  Bosworth's,  according 
to  circumstances)  is  inserted,  and  the  antrum  should  be  thoroughly 
washed  after  each  meal.  When  there  is  no  further  evidences  of  pus, 
the  drainage-tube  is  withdrawn  and  the  opening  heals  very  quickly, 
although  so  long  as  it  persists  the  flushing  of  the  antrum  must  be 
maintained  because  of  the  liability  to  infection  from  food. 

Sometimes,  after  the  operation  has  been  most  thorough,  evidences 
of  chronic  inflammation  again  make  their  appearance  and  the  operation 
must  be  repeated. 

Foreign  Gro"wths. — Cysts  have  been  known  to  exist  within  the 
antrum  of  Highmore,  also  serous  accumulations  and  extravasations 
of  blood.  Tumors,  both  benign  and  malignant,  are  not  relatively 
uncommon,  as  hematomata,  fibromata,  bony  tumors,  myxomata,  and 
both  sarcomata  and  carcinomata.  (According  to  the  table  of  Weber, 
based  on  307  cases  analyzed  by  him,  carcinoma  is  by  far  the  most 
common,  and  sarcoma  next.) 

Symptoms  appear  rather  insidiously,  and  may  be  confined  to  local 
pain  and  distress,  with  the  addition  of  cachexia  and  involvement  of 
glands  in  malignant  disease,  or  there  may  be  evidence  of  involvement 
of  contiguous  structures. 

Extirpation,  if  the  age  and  health  of  the  patient  permit,  is  the  only 
course,  and  even  then  the  trouble  may  be  too  extensive  to  be  checked. 

Frontal  Sinus. — Injuries. — This  cavity  communicates  with  the 
nasal  cavity  through  the  fronto-nasal  canal,  a  relatively  long  and  nar- 
row opening.  It  is  subject  to  simple,  compound,  and  comminuted 
fractures.  The  first  is  usually  the  result  of  direct  violence,  as  a  fall  or 
a  blow  upon  the  forehead,  while  the  last  is  the  result  of  gunshot 
wounds,  stabs,  falls,  blows,  explosions,  etc. 

In  simple  fracture  commonly  only  the  anterior  wall  is  broken,  and 
in  that  case  the  most  frequent  and  serious  symptom  is  emphysema  of 
the  face  and  forehead  because  of  the  escape  of  air  from  the  nose  into 
these  tissues.  The  posterior  wall  of  the  sinus  may  be  fractured,  with 
consequent  access  to  the  brain.  If  the  outer  wall  is  depressed,  it  must 
be  elevated  to  avoid  disfigurement  of  the  face.  If  the  dura  mater  is 
exposed,  an  operation  may  be  necessary. 

In  compound  and  comminuted  fracture  all  pieces  of  bone  or  frag- 
ments of  other  tissue  must  be  removed  from  the  sinus,  and  also  all 
foreign  bodies,  as  bullets  or  splinters.  Jagged  points  of  bone  must  be 
removed,  and  the  parts  restored  as  nearly  as  possible  to  their  normal 
position.     Plastic  operations  may  be  necessary  to  secure  this  end. 

It  is  said  that  the  frontal  sinus  is  the  most  liable  to  invasion  by 


592  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

insects,  as  flics,  centipedes,  etc.  Strict  antisepsis  must  be  maintained 
whatever  the  operation,  and  particularly  if  there  is  likely  to  be  any 
involvement  of  the  brain. 

Diseases. — fiifJaiiiii/atioii  may  either  be  acute  or  chronic.  The 
acute  fonii  is  frequently  caused  by  an  extension  of  inflammation  from 
the  Schneiderian  membrane.  It  is  also  the  result  of  such  injuries  as 
were  described  in  the  previous  section.  It  may  also  result  from  tertiary 
syphilis,  and  whatever  the  cause,  there  may  or  may  not  be  abscess.  From 
the  frequency  with  which  it  is  involved  in  acute  coryza  it  would  seem 
at  first  thought  that  it  is  affected  more  frequently  than  the  other 
accessory  sinuses  of  the  nose,  but  this  probably  is  not  the  case.  The 
canal  to  this  sinus  is  so  narrow  that  it  is  easily  occluded  by  the  swell- 
ing of  its  mucosa.  Secretions  are  thus  retained,  and  consequent  .symp- 
toms appear  eadier  and  are  more  marked  than  in  the  case  of  other 
sinuses,  where  some  outlet  is  generally  preserved,  even  when  the 
mucous  membrane  is  considerably  congested  or  inflamed. 

Svniptflins. — A  sense  of  fulness  in  the  forehead,  intense  headache 
and  pain  in  the  frontal  region,  are  the  usual  symptoms  of  inflammation 
of  the  frontal  sinus  without  abscess.  If  an  abscess  form,  all  these  are 
aggravated,  constitutional  symptoms  appear,  and  local  signs  are  marked. 
There  are  chills,  fever,  and,  if  there  is  pressure  upon  the  brain  or 
invasion  of  it  by  the  products  of  inflammation,  there  may  be  delirium. 
There  are  local  pain  and  tenderness  on  pressure,  bulging  and  distention 
of  the  parts,  even  to  exophthalmos.  If  the  pent-up  pus  finds  access  to 
the  cranial  cavity  and  implicates  the  brain,  there  is  delirium.  Over  the 
affected  part  the  skin  often  becomes  intensely  red,  simulating  erysipelas. 
If  the  inflammation  is  of  syphilitic  or  tubercular  origin,  there  are  very 
likely  both  local  and  constitutional  manifestations  of  its  presence  in  the 
system.  The  eyes  usually  share  in  the  affection  to  some  extent,  photo- 
phobia, conjunctivitis,  and  lachrymation  being  common. 

Absorption  of  the  bone  takes  place  if  the  pressure  is  great,  and 
consequently,  if  there  is  spontaneous  evacuation,  the  pus  finds  vent  at 
the  point  of  least  resistance. 

Fluctuation  and  crepitation  are  often  very  noticeable  before  this 
occurs. 

Treatment. — In  simple  acute  inflammation  without  abscess  pain  may 
be  controlled  by  opium,  with  the  usual  treatment  of  an  acute  coryza, 
and  leeching  if  there  is  fear  of  abscess.  When  there  is  evidence  of  the 
accumulation  of  pus,  free  evacuation  is  the  only  rule.  An  attempt  may 
be  made  to  reach  it  through  the  nasal  outlet.  If  this  fail,  as  it  is  apt  to 
do,  an  external  incision  is  to  be  made,  even  though  it  leave  a  scar. 
The  cavity  is  washed  out  with  disinfectant  solutions  and  a  drainage- 
tube  inserted.  If  syphilis  is  the  cause  of  the  abscess,  necrosed  bone 
will  probably  be  found  ;  this  must  be  carefully  and  completely  removed 
and  specific  treatment  must  be  begun. 

CJironic  inflauiuiatioii  of  the  frontal  sinus  is  generally,  if  not  always, 
purulent.  It  may  be  the  result  of  repeated  attacks  of  acute  inflam- 
mation, or  it  may  be  the  outcome  of  a  single  acute  attack  of  unusual 
severity.  Chronic  inflammation  of  the  Schneiderian  membrane  may 
involve  that  of  the  frontal  sinus ;  also  abnormal  nasal  conditions,  as 
hypertrophy,  a   deviated  septum,  nasal  polypi  (by  causing  partial  ob- 


lyjURIES  AND   DISEASES    OF   THE   RESPIRATORY  SYSTEM.    593 

struction  of  the  fronto-nasal  canal),  will  produce  a  chronic  inflammation 
of  the  mucosa  lining  the  frontal  sinus.  Syphilis  and  tuberculosis, 
foreign  bodies  and  tumors,  are  all  causative  factors  in  producing  chronic 
purulent  inflammation  of  this  sinus. 

Syinptovis. — All  of  the  symptoms  and  local  signs  of  acute  inflam- 
mation may  be  present  in  the  chronic  form,  but  are  generally  less 
severe,  pain  being  rather  dull  and  constant,  with  occasional  re- 
mission, alternating  with  exacerbations.  Pus  is  generally  to  be  seen 
in  the  nose,  but  may  be  so  small  in  amount  as  almost  to  escape  notice. 
If  this  is  the  case — that  is,  if  the  discharge  is  not  marked  and  constant 
— there  is  frequently  an  unusually  large  discharge,  followed  by  a  tem- 
porary quieting  of  all  the  symptoms.  It  is  sometimes  impossible  to 
differentiate  with  certainty  between  a  discharge  of  pus  in  the  nose, 
coming  from  the  frontal  sinus,  and  that  coming  from  the  other  acces- 
sory sinuses,  and,  as  we  have  seen,  it  may  really  come  from  the  maxil- 
lary sinus  when  the  inflammation  is  in  the  frontal  sinus.  If  it  originates 
in  the  maxillary  sinus,  bending  the  head  and  wiping  away  the  pus  will 
stop  its  coming  for  a  time ;  if  it  is  from  the  frontal  sinus,  its  flow  will 
be  continuous.  If,  on  examination  with  a  probe  of  the  ethmoidal 
sinuses,  there  is  no  evidence  of  exposure  of  bone  by  the  absorption 
of  its  mucous  covering,  then  ethmoidal  disease  may  safely  be  excluded. 
If  the  disease  give  evidence  of  having  its  seat  well  forward,  sphenoidal 
disease  may  be  set  aside.  However,  all  the  sinuses  may  be  involved  at 
once,  or  any  two  or  three  of  them.  For  instance,  purulent  inflamma- 
tion originating  in  the  frontal  sinus  may  set  up  the  same  trouble  in  the 
antrum  of  Highmore,  and  it  may  finally  reach  the  ethmoidal  cells  by 
extension  from  the  pituitary  membrane. 

TreatvicJit. — Two  possible  routes  for  evacuation  present  themselves 
— one  through  the  natural  passage,  and  one  by  external  incision  through 
the  frontal  bone.  The  difficulties  are  threefold  in  respect  to  the  former : 
the  opening  to  the  passage  may  not  be  found  by  the  probe  in  the  hand 
of  the  surgeon,  since  we  must  find  it  by  touch  alone,  illumination  being 
out  of  the  question  ;  secondly,  if  by  chance  the  probe  engages  in  the 
proper  orifice,  it  may  be  impossible  to  clear  the  passage  to  the  sinus  ; 
lastly,  there  is  great  danger  to  other  contiguous  localities  should  the 
probe  slip.  So  that,  in  spite  of  possible  deformity,  an  external  incision 
is  the  safer.  It  may  be  made  above  or  below  the  end  of  the  eyebrow, 
but  preferably  below,  because  the  scar  is  there  less  noticeable.  The 
contents  of  the  sinus  are  evacuated,  a  probe  is  passed  downward  into 
the  nose,  and  a  drainage-tube  inserted  into  the  passage,  through  which 
the  sinus  is  washed  out  daily.  The  wound  is  closed  and  dressed  as  in 
other  situations.    Complications  and  sequelae  must  be  met  as  they  occur. 

Mucocele  and  cysts  have  been  frequently  reported  as  found  in  the 
frontal  sinus. 

Foreign  bodies,  as  bullets,  splinters,  and  insects,  have  already  been 
referred  to,  and  in  addition  concretions  similar  to  rhinoliths  may  form 
in  the  frontal  sinus. 

Tumors,  both  benign  and  malignant,  are  of  not  infrequent  occur- 
rence. 

Polypi  and  osteomata  are  the  most  common  types  of  the  former. 
Both  carcinomata  and  sarcomata  are  found,  the  latter  being  the  more 
38 


594  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

common.  Great  deformity  and  destruction  of  parts  from  pressure  are 
the  usual  sequelse,  with  local  and  reflex  symptoms  of  great  variety  and 
intensity  as  the  disease  develops. 

Whether  or  not  extirpation  is  to  be  attempted  must  be  determined 
in  each  case  b\^  its  own  peculiar  character. 

Bthinoidal  Sinuses. — It  is  by  analogy  rather  than  by  demonstra- 
tion that  we  arrive  at  conclusions  regarding  cthmoiditis.  Owing  to  its 
position  and  the  thinness  of  its  mucosa  and  limiting  walls  it  is,  of  all 
the  sinuses,  the  most  prone  to  acute  inflammation  with  or  without 
abscess,  or  to  chronic  inflammation  with  absorption  of  the  mucosa  and 
the  underlying  bone.  But  none  of  these  are  capable  of  demonstration. 
It  is  only  when  the  probe  strikes  bare  bone  that  we  are  absolutely 
certain  of  disease  in  this  locality. 

The  cause  of  ethmoiditis  must  be  chiefly  in  the  extension  of  inflam- 
mation from  the  nasal  fossae.  Diphtheritic  membranes  have  been  formed 
in  the  ethmoidal  cells,  and  ozena  probably  often  arises  here. 

The  syuiptovis  are,  in  the  main,  those  of  acute  rhinitis  or  of  frontal 
disease.     By  exclusion  ethmoiditis  may  probably  be  diagnosed. 

Treatment. — If  the  probe  finds  exposed  bone  or  if  by  exclusion 
ethmoidal  inflammation  has  been  diagnosed,  then  the  curette  affords 
the  only  means  of  relief  after  removal  of  all  polypi,  hypertrophied 
tissue,  and  spurs  of  bone  or  correction  of  deviated  septum  in  the  nasal 
passages. 

Sphenoidal  Sinus. — Sphenoiditis  is  even  more  obscure  and 
doubtful  in  its  manifestations  than  ethmoidal  inflammation,  and  is 
usually  a  complication  or  a  sequel  of  the  latter  disease.  The  sphe- 
noid sinus  lies  in  close  relation  to  so  many  important  structures  that 
it  may  well  be  implicated  in  lesions  affecting  them  ;  on  the  other  hand, 
its  own  injury  or  partial  destruction  would  immediately  be  felt  by  the 
nerves  and  blood-vessels  in  its  neighborhood.  If  it  is  distended  with 
an  accumulation  of  pus,  reflex  and  remote  symptoms  are  caused  from 
the  pressure. 

Diagnosis  is  reached  by  exclusion.  Operations  may  be  through  the 
mouth,  the  orbit  (after  enucleation  of  the  eye),  and  the  nose. 

III.  NEUROSES  OF  THE  NASAL  PASSAGES. 

The  olfactory  nerve  is  the  only  one  concerned  in  the  special  sense 
of  smell,  and  hence  any  abnormalities  as  to  smell  must  be  due  to 
disease  of  this  nerve.  The  fifth  nerve  is  the  nerve  for  common  sensa- 
tion and  touch.  Either  of  these  may  be  affected  separately  or  both 
together. 

Anosmia  is  the  absence  of  smell,  and  strictly  the  term  should  be 
used  to  express  entire  abolition  of  the  sensation.  A  rather  loose  use 
of  it,  however,  permits  us  to  speak  of  the  impaired  sensation  as  partial 
anosmia.  It  may  be  temporary  or  permanent,  because  its  causes 
naturally  fall  generally  into  two  great  groups — those  in  which  the  nerve 
itself  is  injured  or  destroyed,  and  those  in  which  obstruction  in  the 
nasal  cavity  prevents  the  exercise  of  its  function. 

Sometimes  no  cause  can  be  found  to  account  for  the  condition,  and 
then  it  is  said  to  be  idiopathic,  the  real  cause  being  constitutional  or  an 


INJURIES  AXD  DISEASES   OF   THE   RESPIRATORY  SYSTEM    595 

overlooked  traumatism.  It  is  believed  that  there  may  be  inflammation 
or  rupture  of  either  the  olfactory  bulb  or  the  nerve  before  it  reaches  the 
opening  into  the  ethmoid  plate  or  in  passing  through  that  opening, 
or  that  there  may  be  a  hemorrhage  into  the  tissues  of  the  bulb  or  the 
nerve  within  the  cranium.  Tumors  on  the  distended  lateral  ventricles 
pressing  upon  the  nerve  or  its  roots,  particularly  the  external  root,  may 
prevent  its  functional  activity  or  even  destroy  the  nerve.  Blows  upon 
any  part  of  the  head,  since  the  olfactory  bulbs  lie  on  the  floor  of  the 
cranium,  may  sever  the  connection  with  the  brain.  Atrophy  and 
degeneration  of  the  nerve  are  not  unknown.  Besides  lesions  within 
the  cranium,  the  nerve  may  suffer  injury  within  the  nasal  cavity. 
Anosmia  may  be  caused  by  long-continued  hyper-stimulation  from 
powerful  odors.  Well-credited  instances  are  recorded  where  ether  has 
been  the  causative  factor  in  producing  anosmia. 

Douches  have  been  known  to  produce  it,  probably  because  the 
lotions  used  were  too  strong.  Prolonged  rhinitis  is  no  doubt  the  com- 
monest cause  of  temporary  anosmia.  Paralysis  of  the  fifth  nerve  is 
said,  finally,  to  produce  it.  In  the  main,  injuries  to  the  bulb,  the  nerve, 
or  its  terminal  filaments  will  result  in  permanent  anosmia,  though  of 
course  there  may  be  cases  of  temporary  anosmia  where  the  cause  lies 
in  the  lesion  of  the  nerve  itself 

On  the  other  hand,  where  obstruction  produces  the  symptom  it  is 
far  more  apt  to  be  only  temporary,  and  is  generally  only  partial. 

One  has  only  to  recall  the  common  causes  of  obstruction  to  enume- 
rate the  causes  of  obstructive  anosmia — nasal  polypi,  tumors,  hyper- 
trophic rhinitis,  deviated  septum,  crusts  of  inspissated  mucus,  acute 
coryza,  cicatricial  contraction,  etc.  Generally  with  the  removal  of  the 
obstruction  the  power  of  smell  is  regained.  Any  cause  also  which 
produces  dryness  of  the  surface  of  the  mucous  membrane  will  interfere 
with  smell,  as  moisture  is  essential  to  its  exercise.  Paralysis  of  the 
dilator  muscles  of  the  nose  may  cause  temporary  or  permanent  anos- 
mia according  to  the  duration  of  the  paralysis. 

Frequently  anosmia  is  unilateral,  and  may  thus  exist  without  the 
knowledge  of  the  patient.  Plugging  the  other  nostril  is  necessary  then 
to  verify  the  condition. 

Anosmia  may  also  be  due  to  congenital  causes,  either  congenital 
occlusion  of  the  nasal  fossae  or  congenital  absence  of  the  olfactory 
tract. 

Anosmia  is  frequently  observed  in  connection  with  hysteria,  and  is 
then  accompanied  with  the  suspension  of  other  sensations,  as  taste,  all 
of  which  are  believed  to  be  of  central  origin. 

Dr.  William  Ode  has  conducted  researches  to  estabHsh  the  fact 
that  diminution  or  absence  of  pigment  in  the  olfactory  region  impairs 
the  sense  of  smell.     This  may  be  a  coincidence  and  not  a  cause. 

Taste  is  closely  connected  with  smell.  Our  appreciation  of  flavors 
is  really  due  in  large  measure  to  smell,  and  when  this  sense  is  dulled  or 
absent  its  loss  may  first  be  noticed  by  the  fact  that  well-known  flavors 
are  not  recognized  by  the  sense  of  taste. 

Further,  when  the  olfactory  nerve  is  unimpaired  and  the  anosmia  is 
due  to  obstruction,  the  odoriferous  particles  may  reach  the  nerve  at 
times  through  the  posterior  nares. 


596  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

Diagnosis  rests  in  the  obstructive  cases  upon  examination,  otherwise 
upon  the  statement  of  the  patient,  since  it  is  a  subjective  symptom. 

Prognosis  depends  upon  the  cause.  Cases  due  to  obstruction  have 
the  best  hope  of  recovery;  next  in  order  are  those  due  to  rhinitis, 
which  are  almost  hopeless  if  the  rhinitis  is  long  continued.  Anosmia 
due  to  lesions  in  the  nerve  itself  seldom  improve. 

Treatment. — Removal  of  the  obstruction  by  any  of  the  methods 
already  detailed  is  usually  sufficient  for  cases  that  are  due  to  obstruc- 
tion. For  those  due  to  rhinitis  the  treatment  for  that  disease  is  all 
that  can  be  given.  When  the  nerve  is  diseased  little  can  be  done 
except  to  maintain  generally  good  nutrition  of  the  nervous  system. 
Galvanism  has  been  tried,  but  the  strongest  current  that  can  be  used  in 
this  locality  is  too  weak  to  be  of  any  service.  Strychnin  locally  applied 
with  a  brush  is  advocated,  but  the  danger  of  poisoning  by  this  method 
must  not  be  overlooked.  It  is  better  given  as  a  tonic.  If  the  disease 
is  of  central  origin,  treatment  is  useless.  Stimulation  by  snuff  or  strong 
odor  may  be  tried. 

Hyperosmia  or  Hyperesthesia  of  the  Olfactory  Nerve. — 
The  sense  of  smell  may  become  abnormally  acute.  Such  a  condition 
may  exist  apart  from  disease,  or  it  may  be  developed  with  disease  or  as 
a  result  of  disease.  Certain  people  have  a  peculiar  susceptibility  to 
certain  smells,  and  betray  no  special  acuteness  in  respect  to  others ; 
others  possess  an  unusual  sensitiveness  in  smell  while  in  certain  states 
of  health — as,  for  instance,  hysterical  people  not  infrequently  lay  claim 
to  extreme  sensitiveness  in  the  perception  of  odors  or  at  least  of  par- 
ticular odors. 

Closely  connected  with  hyperosmia,  and  perhaps  at  times  not  to  be 
distinguished  from  it,  is  the  condition  known  as  parosmia — a  perverted 
or  altered  appreciation  in  regard  to  smell.  Of  such  a  sort  is  the  odor 
so  often  definitely  perceived  by  epileptics  just  as  the  seizure  is  felt. 
Probably  the  perception  of  odors  by  hysterical  patients  at  times  bor- 
ders closely  upon  parosmia.  Insane  people  often  complain  of  odors, 
usually  disagreeable  ones.  This  may  be  imagination  or  it  may  be  due 
to  structural  changes  in  the  nerve  within  the  cranial  cavity.  Tumors 
within  the  bulbs  or  pressing  upon  them  or  degenerations  of  various 
sorts  are  known  certainly  to  cause  parosmia.  Such  odors  are  usually 
disagreeable  in  themselves  ;  but,  whatever  their  character,  if  they  per- 
sist they  become  unpleasant.  Olfactory  derangements,  such  as  these 
last  described,  must  result  in  anosmia  when  the  obstruction  is  com- 
plete. Certain  people  seem  also  to  have  dull  or  perverted  appreciation 
of  odor  even  when  the  condition  is  far  from  being  anosmia.  Some  are 
uncertain  or  indifferent  as  to  odors,  or  odors  widely  different  may  seem 
to  them  just  the  same.  Such  olfactory  abnormalities  are  not  unlike 
color-blindness  in  the  optic  nerve. 

Reflex  Neuroses. — Of  late  years  much  attention  has  been  given 
in  medical  Hterature  to  the  "  sensitive  reflex  area  "  in  the  nose,  which 
either  by  pathological  conditions  within  the  nose  or  by  irritants  from 
without,  is  so  stimulated  as  to  produce  effects  in  remote  parts  of  the 
body.  Its  location  is  at  the  posterior  end  of  the  middle  and  inferior 
turbinated  bones,  and  somewhat  upon  the  septum  opposite  these  parts. 

The  normal  intent  evidently  of  such  an  area  is  to  protect  the  air- 


INJURIES  AXD   DISEASES    OF   THE   RESPIRATORY  SYSTEM.    597 

passages  against  the  intrusion  of  unsuitable  substances.  It  is  only 
when  the  sensitiveness  of  this  area  exceeds  the  normal  that  the  remote 
effects  of  neuralgia,  photophobic  nausea,  etc.  are  felt  from  its  stimula- 
tion. On  the  other  hand,  atrophy  of  the  mucosa  in  this  region  destroys 
the  reflex  sensitiveness.  Cocain,  locally  applied,  destroys  temporarily 
all  manifestations  of  reflex  irritability. 

Some  of  the  conclusions  based  upon  the  existence  of  this  area  have 
"  proved  too  much,"  and  a  conservative  attitude  may  well  be  maintained 
until  their  importance  and  influence  are  established  by  further  investiga- 
tion and  experiment. 

The  fifth  nerve  may  become  paralyzed,  leading  to  loss  of  sensation 
in  the  Schneiderian  membrane,  or  it  may  become  hyperesthetic  and 
lead  to  violent  and  prolonged  sneezing,  which  is  usually  unimportant, 
but  may  lead  to  hemorrhage. 

IV.  THE   LARYNX. 

I/aryngfOSCOpy  is  the  inspection  of  the  interior  of  the  larynx. 
The  discovery  that  this  portion  of  the  body  can  be  brought  into  view 
for  study  and  treatment  is  of  comparatively  recent  date,  and  marked  a 
decided  advance  in  the  methods  of  treating  throat-diseases. 

Mirrors  have  long  been  employed  for  inspecting  such  parts  of  the 
teeth  as  the  dentist  cannot  readily  see.  Manuel  Garcia,  a  singing-master 
of  London,  employed  such  a  mirror  to  make  investigations  as  to  the 
structure  of  the  larynx.  His  researches  and  experiments,  however, 
went  no  farther  than  to  establish  the  fact  that  phonation  depends  upon 
the  true  vocal  cords.  But  just  as  Garcia  had  employed  the  instrument 
of  the  dentist  to  establish  new  facts  regarding  his  own  profession,  so 
Czermak  of  Pesth,  taking  up  his  investigations  where  Garcia  had 
stopped,  added  a  new  specialty  to  medical  surgery  by  the  use  of  arti- 
ficial light  reflected  from  a  concave  mirror  upon  the  mirror  in  the  throat 
to  produce  an  image  of  the  larynx. 

Laryngoscopic  mirrors  are  made  in  sizes  varying  from  three-eighths 
of  an  inch  to  an  inch  and  an  eighth  in  diameter.  They  must  be  attached 
to  a  firm,  slender  handle  at  an  angle  of  135°.  Those  of  about  an  inch 
are  used  for  adults ;  smaller  ones  are  employed  for  children  and  for 
adults  with  unusually  narrow  fauces. 

Any  convenient  light,  direct  or  reflected,  may  be  used  for  illumina- 
tion, and  here  sunlight  is  really  the  best,  although  a  gas-light  or  elec- 
tric or  oil  light  serves  excellently  well  if  carefully  adjusted  at  the  proper 
angle  and  falling  over  the  right  shoulder  of  the  patient. 

Concentrators  are  not  necessary  if  the  light  itself  is  really  brilliant. 

The  head  reflecting  mirror  has  a  central  perforation,  and  is  mounted 
on  the  head  by  a  band  or  a  spectacle  frame  and  should  move  freely  in 
all  planes.     It  need  not  be  more  than  three  or  four  inches  in  diameter. 

Instead  of  the  head-mirror,  one  attached  to  the  lamp-  or  gas-fixture 
may  be  used,  as  in  Tobold's  laryngoscope  (Fig.  259),  and  for  many  pur- 
poses this  is  simpler  and  easier  to  adjust,  but  the  practitioner  should  be 
master  of  both  methods,  that  his  services  may  be  available  away  from 
his  office. 

When  the  light  is  adjusted  the  patient  opens  his  mouth  as  widely  as 
possible,  extends  his  tongue,  and  keeps  it  in  that  position  by  holding  it 


598 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


with  a  liandkcrchicf  in  his  liancl.  The  surgeon,  having  previously- 
warmed  the  laryngoscopic  mirror,  takes  it  in  his  hand  much  as  he 
would  hold  a  pen,  the  handle  pointing  downward  and  outward.  With 
the  reflecting  surface  outward  he  carries  it  back  over  the  dorsum  of  the 
tongue  until  it  strikes  the  uvula.  This  is  pushed  backward  by  the 
mirror,  the  lower  edge  of  which  should  touch  the  pharynx,  and  all  of 
it  be  plainly  in  view,  its  surface  at  an  angle  of  90°  with  the  line  of 
vision.  Practice  only  makes  these  manoeuvers  both  quick  and  firm 
enough  to  prevent  gagging  on  the  part  of  the  patient,  and  they  should 
be  supplemented  by  most  intimate  knowledge  of  the  regional  anatomy 
of  the  parts  and  of  their  normal  appearance.  Cocain  may  be  applied 
if  there  is  hypersensitiveness  of  the  parts.  Study  of  the  normal  throat  in 
living  subjects  and  of  the  larynx  removed  from   the    cadaver,  both 


Fig.  259. — Tobold's  large  laryngoscope  and  student's  lamp. 


directly  and  with  the  laryngoscopic  mirror,  is  the  only  method  of 
preparation  for  such  work. 

An  artificial  light  gives  to  the  parts  of  the  larynx  a  deeper  color 
than  normal. 

A  little  care  is  necessary  on  the  part  of  the  beginner  in  the  laryngo- 
scopic art  to  appreciate  the  correct  relations  of  the  image  presented  to 
him,  for  he  sees  in  a  nearly  vertical  plane  what  he  has  been  accustomed 
to  think  of  as  a  horizontal  plane,  and  with  the  anterior  and  posterior 
portions  seemingly  reversed.  This  reversal  in  a  normal  throat  should 
be  of  no  moment  whatever.  With  neoplasms  or  other  disease  invading 
the  larynx  a  moment's  reflection  will  assure  the  observer  of  its  real 
position. 

In  the  normal  larynx  the  mucous  membrane  is  of  about  the  same 
color  as  in  other  parts  of  the  body.  Where  the  cartilage,  which  in  this 
region  is  fibro-cartilage,  shows  through,  it  gives  a  yellow  tinge  to  the 
overlying  mucous  membrane.     On  the  other  hand,  it  appears  a  deeper 


INJURIES  AND  DISEASES   OF  THE   RESPIRATORY  SYSTEM.    599 

red  than  in  most  of  its  extent  when  it  overHes  glandular  tissue.  Also 
the  parts  best  illuminated,  those  that  are  farthest  forward  in  the  laryngo- 
scopic  image,  "the  high  lights,"  will  appear  the  lightest  in  tone,  while 
those  that  are  deepest  will  assume  a  darker  hue. 

Repeated  examinations  will  acquaint  the  observer  with  the  normal 
appearance  as  a  whole  as  seen  either  by  sunlight  or  artificial  light,  and 
he  will  be  quick  to  observe  any  departure  from  this  condition  as  indica- 
tive of  disease. 

No  one  position  of  the  throat-mirror  will  suffice  to  reveal  all  portions 
that  become  visible  in  the  successive  positions,  and  the  instrument  must 
be  moved  slightly  to  present  the  best  possible  views. 

The  first  thing  to  be  noted  in  the  laryngoscopic  image  is  the 
epiglottis.  Behind  and  above  this  is  visible  a  portion  of  the  base  of 
the  tongue.  At  the  lowest  part  of  the  arch  of  the  epiglottis  on  each 
side  are  the  lingual  fossae,  separated  by  the  middle  glosso-epiglottic 
ligament  and  bounded  externally  by  lateral  ligaments  of  the  same 
name.  A  view  of  the  lingual  face  of  the  epiglottis  shows  these  three 
ligaments  or  folds  of  mucous  membrane  passing  from  above  downward, 
connecting  the  tongue  with  the  epiglottis.  On  the  laryngeal  face  of  the 
epiglottis  is  seen  the  cushion  of  the  epiglottis,  a  rounded  portion  some- 


FlG.   260." 


-The  laryngeal  image  during  pho- 
nation. 


Fig.   261.- 


-The   laryngeal  image  during  in- 
spiration. 


what  higher  than  the  rest ;  at  about  the  center  of  the  face  we  also  see 
the  posterior  portion  of  the  anterior  palatine  folds,  and  also  the  poste- 
rior palatine  folds,  the  ligaments  attaching  the  tongue  to  the  hyoid 
bone,  and  those  connecting  the  epiglottis  to  the  same  bone  and  the 
posterior  and  lateral  portions  of  the  tonsils.  All  the  parts  so  far  men- 
tioned are  really  exterior  to  the  larynx  proper,  but  incidentally  come 
into  view  as  the  mirror  is  placed  in  position  for  inspection  of  the 
larynx,  and  are  not  visible  by  direct  inspection. 

Within  the  larynx  are  to  be  inspected  the  parts  at  the  level  of  the 
vocal  cords  and  a  variable  portion  of  the  walls  of  the  larynx  and 
trachea  below  that  plane. 

Most  distinctively  in  the  center  of  the  larj'ngoscopic  image  are  seen 
two  white  glistening  bands,  the  true  vocal  cords.  They  may  serve  as 
landmarks  from  which  other  parts  are  located  on  either  side.  During 
the  act  of  phonation  they  are  approximated  closely,  and  it  is  then  im- 
possible to  view  the  parts  below  (Fig.   260).     During  inspiration  the 


600  SURGICAL    DIAGNOSIS  AND    TREATMEA'T. 

vocal  cords  arc  widely  separated,  and  it  is  during  this  interval  that  the 
parts  in  the  lower  part  of  the  larynx  and  upper  part  of  the  trachea  must 
be  inspected  (Fig.  261).  The  rima  glottidis  is  thus  seen  to  vary  in  extent 
from  a  mere  line  in  phonation  to  an  opening  of  relatively  large  dimen- 
sions during  respiration. 

Immediatel)'  external  to  the  true  vocal  cords  on  either  side  are  to  be 
seen  the  ventricular  bands  or  false  vocal  cords,  the  entrance  to  the 
ventricular  looking  like  a  dark  band  next  to  the  true  vocal  cords.  Ex- 
ternal to  the  ventricular  bands  and  somewhat  posterior  to  them  are  the 
arytenoid  cartilages.  They  nearly  meet  behind  the  vocal  cords  when 
the  latter  are  appro.ximated,  but  arc  shorter  and  farther  apart  during 
inspiration.  Between  the  posterior  ends  of  the  arytenoid  cartilages  lies 
the  arytenoid  commissure. 

Forming  the  lateral  walls  of  the  larynx  and  merging  into  the 
arytenoid  commissure  are  the  aryepiglottic  folds,  ridges  of  mucous 
membrane  that  arise  from  the  lateral  border  of  the  base  of  the  epiglot- 
tis. Lying  upon  the  arytenoid  cartilages  can  sometimes  be  made  out 
the  cartilages  of  Santorini.  The  "  staff  of  Wrisberg  "  is  also  observed, 
and  the  vocal  processes  during  respiration.  On  either  side  of  the 
aryepiglottic  folds  are  seen,  darkly  shaded  in  the  image,  the  laryno- 
pharyngeal  sinuses. 

During  inspiration  the  infraglottic  portions  of  the  larj'nx  are  in- 
spected, showing  the  mucous  surfaces  of  the  cartilages  forming  the 
larynx,  the  cartilaginous  ring  of  the  trachea,  and,  in  exceptional  cases, 
its  bifurcation  into  the  bronchial  tubes. 

Such  is  the  normal  appearance  of  the  human  larynx.  The  surgeon 
will  find  in  studying  lesions  of  the  larynx  alterations  in  either  its  mucous 
membranes  or  its  shape,  injuries  or  neoplasms. 

Injuries  of  the  I/arynx. — These  are  produced  by  the  operation 
of  internal  or  external  causes,  the  former  chiefly  by  foreign  bodies 
within  the  larynx,  by  burns  or  scalds  ;  the  latter  in  a  great  variety  of 
ways,  accidental  or  intentional. 

Internal  injuries  may  also  result  from  intra-laryngeal  operations  un- 
skilfully performed,  also  from  substances  vomited,  especially  in  the 
case  of  the  insane  and  of  patients  under  anesthesia. 

Internal  injuries  caused  by  the  entrance  of  foreign  bodies  into  the 
larynx  are  very  common,  and  vary  greatly  in  the  severity  of  the  lesion 
and  the  urgency  of  the  symptoms,  since  the  number  of  different  objects 
that  may  find  their  way  into  the  larynx  is  wellnigh  innumerable.  To 
attempt  to  make  a  list  of  the  objects  that  have  entered  or  may  be  found 
in  that  cavity  is  useless,  for  any  object  that  may  be  placed  in  the  mouth, 
thoughtlessly  or  otherwise,  may  slip  past  the  fauces  and  find  lodgement 
in  the  larynx.  The  student  can  enumerate  them  for  himself,  placing  as 
most  common  those  objects  which  children  especially  are  apt  to  have  in 
their  hands,  as  toys,  or  can  most  easily  obtain  from  their  surroundings. 

The  closing  of  the  passage  may  be  so  complete  as  to  prove  fatal 
almost  immediately,  or  the  object  may  be  such  as  to  remain  concealed 
in  the  mucous  membrane  and  excite  an  extreme  or  only  a  slight  degree 
of  congestion  or  inflammation.  Objects  may  reach  the  interior  of  the 
larynx  also  from  without,  as  bullets  or  the  detached  fragments  of 
sharp-pointed   weapons    or    instruments.     Internal    wounds    may    be 


INJURIES  AND  DISEASES   OF   THE   RESPIRATORY  SYSTEM.    6oi 

punctured,  lacerated,  or  contused.  The  foreign  bodies  may  be  quite 
accessible,  or  may  be  so  deeply  buried  in  the  tissues,  either  from  the 
mode  of  entrance  or  from  subsequent  swelling  of  the  parts,  as  to  make 
it  almost  impossible  to  locate  them.  Even  when  there  is  no  real  wound 
of  the  laryngeal  mucous  membrane  there  may  be  spasm  of  the  glottis, 
and  respiration  be  so  interfered  with  that  the  results  are  fatal.  S}'mp- 
toms  of  pronounced  character  may  be  wanting,  and  from  such  a  nega- 
tive condition  there  are  symptoms  of  varying  severity  up  to  those 
of  great  intensity.  Pain,  cough,  laryngeal  and  phar>'ngeal  neuroses, 
spitting  of  blood,  extravasation  of  blood  into  underlying  connective 
tissue,  and  severe  inflammation  of  mucous  membrane  are  the  usual 
symptoms  in  cases  of  this  sort. 

On  evidence  of  laryngeal  irritation,  whether  the  history  of  the 
entrance  of  a  foreign  body  can  be  obtained  or  not,  a  laryngoscopic 
examination  should  be  made.  If  the  foreign  body  is  visible,  it  is  gen- 
erally easily  removed.  If  it  is  concealed  by  tumefaction  of  the  tissues, 
measures  must  be  taken  to  reduce  the  swelling  by  the  use  of  astringents 
and  local  sedatives.  In  cases  where  its  presence  is  undoubted,  but  it  is 
too  low  to  be  demonstrated,  tracheotomy  may  be  performed,  and  this 
operation  may  be  necessary  if  the  bleeding  has  been  so  considerable  as 
to  cause  an  obstruction  in  itself 

Burns  and  scalds  of  the  larynx  usually  are  accompanied  by  similar 
lesions  of  the  tongue,  mouth,  throat,  pharjmx,  esophagus,  and  even  of 
the  nasal  passages.  Burns  are  produced  by  the  inhalation  of  steam, 
hot  air,  and  smoke  during  fires.  Scalds  are  due  to  hot  and  caustic 
fluids,  swallowed  usually  without  design. 

When  it  is  intended  to  swallow  such  fluids,  they  quickly  pass  the 
epiglottis  ;  when  not,  the  instinctive  effort  to  arrest  deglutition  throws 
them  back  upon  the  larynx,  which  often  then  suffers  the  most  of  any 
of  the  structures  exposed  to  the  action  of  the  fluid.  Acute  laryngitis 
of  an  intensely  severe  type  immediately  follows,  and  usually  implicates 
not  the  mucous  membrane  alone,  but  the  underlying  tissues,  the  extent 
of  such  involvement  depending  upon  the  degree  of  heat  and  the  con- 
centration of  the  fluid.  Edema  of  the  lar>'nx  is  an  almost  constant 
attendant  of  such  lesions,  and  constitutes  one  of  the  chief  dangers. 

Burns  and  scalds  produced  by  hot  water,  air,  and  steam  assert 
themselves  at  once,  while  the  destructive  effects  of  many  caustics  are 
less  prompt.  Pain  of  an  agonizing  character  is  the  most  distinctive 
symptom. 

If  life  be  not  at  once  sacrificed,  sloughing  of  necrosed  tissue  will  be 
followed  by  cicatricial  contraction,  which  in  itself  may  later  present 
problems  of  no  small  difficulty  to  the  surgeon. 

If  suffocation  is  imminent,  tracheotomy  should  be  immediately  per- 
formed, and  morphin  injected  subcutaneously  to  relieve  the  intense 
sufiering.  Cooling  and  soothing  washes  may  be  used  both  upon  the 
lar}mx  and  accompanying  lesions  of  the  mouth,  nose,  and  throat ;  but 
the  outlook  is  very  bad  at  best  in  severe  cases  of  this  sort.  Such  cases 
are  commonly  the  attempts  of  the  insane  or  of  the  sane  would-be 
suicides,  and  the  condition  is  concealed  as  long  as  possible,  thus  losing 
the  advantage  of  prompt  assistance.  Too  much  stress  cannot  be  laid 
upon  the  imminent  danger  of  edema  of  the  larynx,  whatever  the  cause 


602  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

or  nature  or  severity  of  the  injury.  It  has  been  known  to  occur  even 
when  the  offendini^  substance  entered  the  larynx  during  the  act  of 
vomiting. 

If  the  outlook  is  fairly  favorable  for  recovery,  it  is  altered  for  the 
worse  if  at  any  time  suppuration  supervene. 

External  injuries  of  the  larynx  are  caused  in  many  ways,  either 
intentionally  or  accidentally.  In  battle  the  larynx  seems  to  sustain 
relatively  few  injuries,  and  blows,  whether  accidental  or  designed  and 
however  aimed,  seem  more  often  to  fall  upon  the  back  or  side  of  the 
neck  than  upon  the  front  part.  Attempts  at  homicide  or  suicide  afford 
the  largest  number  of  external  injuries  of  the  larynx.  They  are  con- 
tused, punctured,  lacerated,  incised,  and  gunshot  wounds.  Contused 
wounds  from  accident  or  design,  and  incised  wounds  made  with  the 
intent  to  take  life,  greatly  exceed  all  others  in  number.  From  this 
cause,  as  well  as  clinically,  fractures  of  the  larynx  may  be  regarded  as 
a  species  of  contused  wound,  since,  although  injury  may  be  very 
slight,  it  may  be  so  considerable  as  to  fracture  a  cartilage,  generally 
the  cricoid  or  the  thyroid  (without  interruption  to  the  continuity  of 
the  integument).  Rupture  of  muscles  and  ligaments  or  of  the  vocal 
cords,  dislocation  of  other  cartilages,  fracture  of  the  hyoid  bone,  and 
injuries  to  the  trachea  similar  to  those  of  the  larynx  may  all  be  asso- 
ciated with  fracture  of  the  larynx.  Kicks  from  animals,  falls,  blows 
with  the  fist  or  weapons,  may  be  the  cause  of  such  injuries.  The 
greater  number  of  them,  however,  are  produced  by  attempts  at  stran- 
gulation by  the  hands  of  an  assailant  or  by  homicidal  or  suicidal 
attempts  with  rope  or  strap  or  improvised  cord. 

Extravasations  of  blood  into  the  tissues  beneath  the  integument  are 
usually  associated  with  injuries  to  the  larynx. 

Punctured  wounds,  even  in  battle,  are  rare.  In  civil  life  they  result 
from  accident,  generally  by  falling  upon  sharp-pointed  sticks  or  por- 
tions of  machinery. 

The  same  may  be  said  of  lacerated  wounds.  Their  cause,  aside 
from  gunshot  wounds,  is  the  crushing  force  of  some  jagged  instru- 
pient,  as  broken  glass  or  crockery  or  the  cog-wheels  or  other  portions 
of  machinery. 

Incised  wounds  of  the  larynx  outnumber  all  other  varieties  put 
together,  because  a  "cut-throat"  seems  to  the  ordinary  murderer  or 
suicide  to  offer  so  ready  a  means  of  putting  an  end  to  life.  Yet  the 
fact  that  the  case  so  often  falls  into  the  surgeon's  hands  before  it 
reaches  the  undertaker's  shows  that  a  miscalculation  is  made  some- 
where. A  much  neater  piece  of  work  from  a  chirurgical  point  of  view 
would  be  the  severance  of  the  large  vessels  of  the  neck,  and  much 
more  certain  and  effective  from  the  standpoint  of  the  original  operator 
if  he  were  not  too  ignorant  to  appreciate  what  he  is  missing  in  every 
sense  of  the  word.  The  would-be  suicide  stretches  back  his  throat  and 
makes  a  gash  from  left  to  right  generally,  and  if  the  knife  goes  in 
deeply  enough  he  may  injure  all  structures  from  integument  to  pharynx ; 
he  may  sever  the  epiglottis  at  any  place  between  its  free  border  and  its 
attachment  at  the  angle  of  the  thyroid  cartilages  ;  he  may  cut  the  vocal 
cords  or  any  of  the  cartilages  of  the  larynx,  gash  the  thyroid  gland 
and  tongue,  injure  the  hyoid  bone,  or  he  may  cut  low  down,  and,  ex- 


IA[/URIES  AND   DISEASES    OF   THE   RESPIRATORY  SYSTEM.    603 

pending  the  force  of  his  blows  on  the  trachea,  the  larynx  may  escape 
almost  or  wholly  uninjured.  The  gash  is  generally  a  long  one,  and 
retracts  greatly,  and  yet  with  such  injuries  as  those  mentioned  it 
is  not  necessarily  fatal.  The  sterno-cleido-mastoid  muscles  are  ad- 
vanced and  lie  over  the  large  blood-vessels  of  the  neck,  so  that  the 
latter  escape.  There  may  be  considerable  hemorrhage  from  smaller 
vessels,  and  if  this  find  its  way  into  the  trachea,  it  may  cause  suffo- 
cation. If  there  is  much  hacking  of  the  cartilages,  portions  may  fall 
into  or  over  the  trachea  in  such  a  way  as  to  obstruct  respiration 
completely. 

Gunshot  wounds  of  the  larynx,  either  from  bullets  or  bits  of  shell, 
are  uncommon  except  in  the  army  during  battles.  The  relative  infre- 
quency  of  such  injuries  in  military  service  is  a  matter  of  remark.  They 
make  up  the  greater  number  of  lacerated  wounds,  although  they  may 
cause  a  contused  wound,  depending  somewhat  upon  the  force  of  the 
missile.  The  comparative  immunity  of  the  larynx  from  injury  when  it 
is  apparently  not  less  exposed  than  other  parts  of  the  body  is  no  doubt 
largely  due  to  the  resiliency  of  its  cartilages,  so  that  a  ball  striking  it 
is  deflected. 

Symptoms. — The  symptoms  of  injuries  to  the  larynx  from  external 
causes  are  usually  self-evident,  the  only  exception  being  in  some  con- 
tused wounds.  In  such  cases  the  bruise  will  be  suggestive.  If,  in 
addition,  there  are  pain  and  tenderness  on  pressure  or  in  deglutition, 
dyspnea,  cough,  bloody  expectoration,  retraction  of  muscles,  nervous 
manifestations,  swelling  of  the  integument,  the  symptoms  are  certainly 
characteristic  and  make  the  diagnosis  very  clear.  Laryngoscopic  ex- 
amination may  reveal  tumefied  and  reddened  or  lacerated  tissues  or 
ruptured  structures. 

In  punctured  wounds,  besides  the  external  appearances,  emphysema 
is  common,  and  threatened  suffocation  the  rule  from  the  emph)'sema 
and  the  presence  of  blood  in  the  larynx  and  trachea. 

Incised  "Wounds. — Most  prominent  and  important  of  all  the  sj^mp- 
toms  is  the  wound  itself,  and  the  other  symptoms  depend  largely  upon 
its  extent.  If  it  is  small,  the  hemorrhage  may  be  less  than  when  it  is 
large,  but  more  dangerous  from  the  fact  that  in  such  a  case  it  is  more 
apt  to  find  its  way  into  the  trachea  and  cause  suffocation.  In  any  case, 
even  if  the  large  vessels  are  not  implicated,  hemorrhage  is  apt  to  be  an 
important  symptom  and  an  important  factor  in  the  prognosis,  for  the 
blood-supply  is  large  here,  and,  either  from  the  primary  or  the  second- 
ary hemorrhage,  suffocation  is  imminent. 

Fragments  of  tissue  also  may  occlude  the  trachea  dangerously  or 
fatally. 

The  patient  is  weak  from  loss  of  blood,  may  suffer  extreme  thirst, 
and  lose  his  voice  from  injury  to  the  vocal  cords  or  from  gaping  of  the 
wound.  If  the  pharynx  is  involved,  swallowing  may  be  difficult  or 
impossible.  There  may  be  distressing  cough  from  the  blood  in  the 
trachea,  and  the  mental  and  physical  distress  which  always  attends 
dyspnea  is  present.  Emphysema  is  common.  Fluids  swallowed  may 
escape  through  the  incision.  There  is  great  pain,  usually  with  great 
tenderness  of  surrounding  parts. 

Gunshot  -wounds  may  be  attended  by  any  or  all  of  the  symptoms 


604  SURGICAL   DIAGNOSIS  AND  TREATMENT. 

characteristic  of  other  wounds,  and,  in  addition,  arc  most  apt  to  be 
followed  by  neuroses  of  one  sort  or  another. 

In  all  wounds  of  the  larynx  a  secondary  hemorrhage  which  may 
quickly  cause  suffocation  is  to  be  feared  after  the  closure  of  the  exter- 
nal wound. 

Diagnosis  is  based  upon  the  wound  and  resultant  symptoms. 

Prognosis  must  be  guarded,  although  it  is  not  wholly  unfavorable. 
Sometimes  with  small  contused  or  gunshot  wounds  the  shock  is  greater 
than  with  large  incised  wounds,  and,  on  the  whole,  the  latter,  even 
though  extensive,  promise  the  best  as  to  recovery. 

If  the  patient  survive  both  primary  and  secondary  hemorrhages,  the 
system  may  finall)^  yield  to  the  shock  and  depiction,  or  suppuration  may 
supervene  at  a  later  date  in  the  wound  itself  or  in  the  air-passages. 
Pneumonia  is  a  frequent  result  of  the  entrance  of  blood  and  other 
extraneous  substances  into  the  air-passages. 

So  much  of  injured  tissue  may  eventually  slough  as  will  bring 
about  a  fatal  issue  by  causing  septic  infection  or  by  reopening  the 
wound. 

Finally,  after  the  healing  of  the  wound,  gaps  and  fissures  may 
remain ;  the  function  of  the  parts  may  never  be  fully  restored ;  and 
cicatricial  contraction  may  go  on  to  such  an  extent  as  to  endanger 
life  by  stenosis.  If  there  is  not  cicatricial  contraction,  the  cartilages 
may  be  enlarged  and  distorted  by  the  healing  process  until  the  function 
is  greatly  impaired. 

Treatment. — In  most  severe  cases  of  injury  to  the  larynx  after 
removal  of  extraneous  substances  from  the  trachea,  tracheotomy  is  the 
first  step  in  treatment,  because  suffocation  is  imminent,  either  immedi- 
ately or  when  tumefaction  of  the  tissues  shall  have  begun,  or  when 
secondary  hemorrhage  shall  have  set  in  after  recovery  from  syncope. 
Even  in  wounds  of  comparatively  slight  importance  the  surgeon  will 
save  himself  all  possibility  of  unpleasant  future  complications  if  trache- 
otomy be  performed  as  a  prophylactic  measure  in  a  course  of  treat- 
ment that,  under  favorable  circumstances,  is  certain  to  be  long  and 
tedious. 

The  next  step  is  the  stopping  of  hemorrhage.  If  large  vessels — 
either  of  the  thyroids,  for  instance — have  been  severed,  they  should  be 
ligatured  ;  compression  and  the  application  of  cold  may  be  of  service,  or 
the  local  application  of  astringents. 

Hemostatics  may  be  given  internally.  If  hemorrhage  prove  ob- 
stinate, it  may  be  necessary  to  ligature  the  carotid.  The  strength  of 
the  patient  must  be  maintained  by  prompt  stimulation  either  hypo- 
dermically  or  per  rectum. 

With  these  preliminaries  disposed  of,  the  surgeon  must  as  speedily 
as  possible  give  his  attention  to  the  condition  of  the  wound  itself 
He  must  study  it  that  he  may  determine  his  method  of  procedure 
before  the  tissues  are  distorted  by  swelling,  and  also  that  he  may 
remove  any  fragments  that  cannot  be  saved,  le.st  they  in  some  way 
occlude  the  air-passages.  If  the  tongue  is  severed,  the  parts  should 
be  sutured  to  prevent  the  posterior  portion  from  falling  back  upon 
the  larynx. 

It  is  seldom  of  any  avail  to  attempt  to  suture  the  cartilages,  not 


INJURIES  AND   DISEASES    OF   THE   RESPIRATORY  SYSTEM.    605 

even  portions  of  the  epiglottis  uniting  kindly.  If  the  wound  is  later- 
ally extensive,  some  sutures  may  be  placed  through  the  soft  paits  at 
its  extremities.  If  the  wound  were  entirely  closed,  there  would  be 
great  danger  from  suffocation  from  secondary  hemorrhage,  and  em- 
physema is  much  less  easily  controlled  if  the  wound  is  sutured  in  its 
entire  extent. 

If  the  wound  is  not  extensive,  sutures  may  be  entirely  dispensed 
with.  The  edges  of  the  wound  are  coapted  and  held  in  position  by 
strips  of  adhesive  plaster.  The  position  of  the  patient  is  important. 
He  must  be  so  placed  in  a  semi-reclining  position  that  the  head  in- 
clines enough  to  favor  close  juxtaposition  of  the  edges  of  the  wound 
without  their  overlapping.  The  head  is  then  held  immovable  by 
bandages  skilfully  applied  over  the  head  and  fastened  to  a  band  under 
the  arms  or  around  the  waist.  Rather  loose  antiseptic  dressings  should 
be  placed  over  the  w^ound,  and  frequently  inspected  that  exudations  may 
be  promptly  wiped  away.  If  suppuration  occur,  its  treatment  is  the 
same  as  in  other  wounds. 

Unless  the  pharynx  has  been  wounded  also,  there  is  generally  little 
difficulty  in  feeding  the  patient.  If,  however,  for  any  reason,  the  wound 
is  distended  in  taking  food,  the  surgeon  must  be  equal  to  the  emergency 
by  placing  tubes  in  throat  or  nostrils  or  by  providing  for  rectal  alimen- 
tation. 

There  is  generally  a  tendency  to  cough  from  the  presence  of  blood 
or  other  liquids  or  excessive  secretions  due  to  the  irritation.  This 
must  be  repressed  by  the  administration  of  codeine  or  opium. 

Sometimes,  especially  if  there  is  no  tearing  open  of  the  wound, 
there  may  be  little  cicatrization.  Occasionally  fistulous  openings  remain, 
which  always  must  be  covered,  both  for  appearances  and  to  preserve 
the  function  of  phonation,  or  a  plastic  operation  may  be  done  to  fill 
the  breach. 

If  stenosis  of  the  trachea  or  larynx  result  from  cicatricial  contraction, 
it  is  best  corrected  by  gradual  dilation,  though  persistent  efforts  in  this 
direction  are  sometimes  wholly  fruitless. 

Foreign  Bodies  in  the  Air-passages. — No  accident  is  more 
common  than  the  entrance  of  some  substance  into  the  air-passages.  It 
may  occur  during  the  act  of  sw^allowing,  when  for  some  reason  the 
epiglottis  has  failed  to  close  normally,  or  if  something  is  being  held  in 
the  mouth,  a  careless  habit  in  which  no  one  should  indulge,  and  to 
which  children  are  especially  prone,  a  sudden  inspiration  may  carry  it 
into  the  larynx,  where  it  may  remain  or  pass  on  into  the  trachea. 
During  dental  operations  or  those  upon  the  mouth  and  throat  for- 
eign substances  like  a  fragment  of  tooth,  the  cork  or  bit  of  wood 
which  has  been  used  as  a  gag  to  keep  the  teeth  apart,  bits  of  sponge, 
or  fluid  may  find  their  way  into  the  windpipe.  Emesis,  especially 
during  anesthesia,  may  provide  the  substance  that  enters  the  air- 
tube.  Artificial  teeth  have  an  uncomfortable  habit  of  traveling  back- 
w^ard,  especially  during  sleep.  A  bronchial  gland  or  large  masses  of 
mucus  or  quantities  of  blood  may  be  coughed  up  and  occlude  the 
trachea  or  larynx  from  below.  Foreign  bodies  may  enter  by  per- 
forating the  external  wall,  as  bullets  in  gunshot  wounds.  They  may 
also  work  their  way  in  from  the  interior  parts  of  the  body  by  pene- 


6o6  SURGICAL   DIAGNOSIS  AND    TREATMEmXT. 

trating  the  tracheal  wall,  as,  for  instance,  from  the  esophagus.  Foreign 
bodies  may  also  enter  the  air-passages  through  wounds  previously 
sustained. 

In  most  cases  reflex  cough  or  spasm  is  at  once  excited ;  the  sub- 
stance is  expelled  almost  before  it  has  found  lodgement,  and  the  affair 
is  forgotten.  In  others  vigorous  slaj)ping  upon  the  back,  or  at  most 
inversion  of  the  patient  with  slapping,  brings  to  a  happy  termination  the 
slight  struggle  for  breath  and  the  choking  sensation. 

In  others  the  foreign  body  is  not  expelled,  and  the  annoyance  and 
discomfort  from  its  presence  are  slight  and  transient.  In  others  dis- 
tressing symptoms  occur  at  intervals.  In  still  others  severe  laryngitis, 
even  of  a  suppurative  form,  asserts  itself  with  more  or  less  rapidity.  In 
others  there  is  immediate  distressing  dyspnea  and  the  services  of  the 
surgeon  are  in  urgent  demand.  In  still  others  the  occlusion  is  so  com- 
plete that  a  fatal  termination  is  immediate,  and  that  under  circum- 
stances most  painful  and  agonizing. 

Organic  materials  are  apt  to  undergo  changes,  even  decomposition. 
Seeds,  for  instance,  may  increase  in  size  from  absorption  of  moisture  if 
long  retained  in  the  air-passages.  Inorganic  substances  may  become 
almost  encysted,  so  covered  are  they  with  secretions  and  calcareous 
deposits.  Those  of  smooth  outline  and  small  size  may  remain  indef- 
initely without  serious  discomfort,  but  never  without  danger  from 
possible  change  of  position. 

Symptoms. — Symptoms  may  be  almost  or  wholly  negative,  or  they 
may  remain  in  abeyance  until  the  irritation  has  induced  a  laryngitis 
which  is  obstinately  prolonged.  Generally,  however,  there  is  spasm 
of  the  glottis,  spasmodic  cough,  pain,  and  change  of  color,  the  face 
becoming  at  first  crimson  and  then  purple.  The  eyes  may  protrude, 
and  the  countenance  express  the  utmost  anxiety  and  distress.  The 
patient  throws  himself  about  and  tears  at  his  throat.  This  may  be  fol- 
lowed by  unconsciousness,  from  which  he  may  recover  or  which  merges 
into  death,  or  the  spasm  may  pass  and  an  almost  or  a  quite  normal 
state  be  regained.  Only  one  paroxysm  may  ensue,  or  the  first  may  be 
succeeded  by  others  at  regular  or  irregular  intervals.  Even  when  the 
initial  symptoms  are  comparatively  slight  a  change  of  location  of  the 
intruding  body  may  suddenly  precipitate  secondary  spasms  of  great 
severity.  There  may  be  dysphagia  from  pressure  on  the  esophagus. 
Local  pain  usually  indicates  where  the  foreign  body  has  lodged, 
cough  is  common  if  it  is  in  the  trachea  or  bronchus,  and  hoarseness 
or  aphonia  will  follow  its  lodgement  in  the  larynx. 

Severe  lesioas  of  the  lungs  may  either  be  simulated  or  actually  exist 
as  a  result  of  the  introduction  of  foreign  bodies  into  the  air-passages, 
according  to  the  nature  and  location  of  the  offending  matter. 

Diagnosis. — With  a  history  of  the  intrusion  of  a  foreign  body  into 
the  air-passages  diagnosis  is  a  matter  of  no  difficulty.  Where  such  a 
history  is  not  forthcoming  and  laryngoscopic  examination  reveals 
nothing,  the  diagnosis  is  exceedingly  difficult.  If  the  body  is  of  hard 
material,  the  probe  may  reveal  its  presence,  but  not  necessarily.  Aus- 
cultation will  assist  to  some  extent.  If  a  tube  be  largely  but  not  wholly 
occluded,  a  sonorous  rale  will  be  betrayed.  If  it  is  wholly  occluded, 
respiratory   murmur  will   be   wanting.       Unilateral    bronchitis    should 


INJURIES  AND   DISEASES   OF   THE   RESPIRATORY  SYSTEM.    6oj 

always  suggest  the  presence  of  a  foreign  body  in  the  lower  air-passages. 
Difficult  respiration  will  suggest  that  rather  than  disease. 

Prognosis. — This  is  always  grave.  Even  if  the  comfort  of  the 
patient  is  not  seriously  interfered  with,  there  is  always  danger  in 
change  of  location  and  in  the  possibility  of  the  lighting  up  of  an 
acute  inflammation  or  in  the  supervention  of  edema.  The  substance 
may  be  expelled  spontaneously,  but  if  its  presence  is  unquestionable, 
no  risks  should  be  taken  ;  it  should  be  removed.  After  spontaneous 
expulsion  recovery  is  usually  complete,  but  death  has  resulted  from  the 
inflammation  set  up  before  its  expulsion. 

Treatment. — If  the  symptoms  are  not  imperative,  slapping  upon  the 
back  and  inversion  are  naturally  first  tried. 

Removal  by  the  natural  orifice  is  desirable  if  possible.  If  the  object 
can  be  located  by  the  laryngoscope,  it  may  then  generally  be  removed 
by  the  finger  or  by  slender  forceps  suitably  curved.  Cusco's  larj^-ngeal 
forceps  are  a  most  excellent  instrument.  Flexible  forceps  may  be 
bent  at  the  desired  angle  (Fig.  262). 


Fig.  262. — Cusco's  laryngeal  forceps. 

Substances  of  irregular,  jagged  shape  must  be  xtxy  carefully  manip- 
ulated in  order  not  to  tear  the  tissues  during  their  removal,  and  such 
as  can  be  so  treated  should  be  crushed,  as  nutshells,  and  removed 
piecemeal  or  coughed  up. 

If  none  of  these  expedients  succeed,  tracheotomy  must  be  per- 
formed, and  sometimes  it  should  be  done  as  a  precautionary  measure, 
lest  in  efforts  to  remove  the  object  through  the  larynx  it  assume  such 
position  as  to  occlude  the  larynx  or  trachea  completely. 

Whether  the  operation  should  be  above  the  thyroid  gland,  through 
it,  or  below  it  depends  upon  the  shape,  position,  and  size  of  the  object, 
and  upon  the  shape  of  the  neck  to  be  operated  upon.  Unless  it  is 
absolutely  certain  that  the  foreign  body  lies  high,  the  low  operation  is 
to  be  chosen,  for  there  is  more  space  here  than  above  the  glands  for 
operating,  and  the  gland  is  so  very  vascular  as  to  make  it  desirable  to 
avoid  wounding  it  if  possible.  However,  if  the  incision  must  go 
through  the  gland,  the  isthmus  should  be  ligatured  twice  and  cut 
between  the  ligatures.  The  edges  of  the  wound  must  be  retracted, 
and  an  improvised  retractor  will  serve  very  well,  though  good  instru- 
ments are  made  for  the  purpose  (Fig.  263).  The  incision  should  be 
an  inch  or  an  inch  and  a  quarter  in  length.     Ordinarily,  if  the  object  is 


6o8  Si'KGICAL    n/A GNOSIS  AND    TREATMENT. 

in  the  trachea  or  bronchial  tubes,  it  at  once  presents  itself  at  the  open- 
ing, is  spontaneously  expelled,  or  can  be  easily  removed  by  the  surgeon. 
Slapping  upon  the  back  and  inversion  will  remove  more  obstinately 
retained  objects.  The  surgeon  may  blow  or  force  air  into  the  opening, 
and  the  expiration  of  this  condensed  air  will  usually  force  out  the 
object.  Search  may  have  to  be  made  for  it.  It  is  rare,  indeed,  that 
tracheotomy  docs  not  succeed ;  if  not  at  first,  then  after  the  inflamma- 


FlG.  263. — Minors  trachea-retractors. 

tion  of  the  tissues  has  had  time  to  subside.     The  ingenuity  of  the 
surgeon  will  usually  overcome  all  difficulties. 

Diseases  of  the  Larynx. 

I^aryngitis. — Catarrhal. — Acute  laryngitis  usually  involves  the 
whole  larynx,  but  it  is  not  uncommon  to  find  the  disease  limited  to  one 
or  several  parts,  constituting  the  circumscribed  variety.  Thus  the  vocal 
cords  alone  might  suffer,  but  commonly  a  cause  sufficient  to  affect 
them  would  implicate  also  the  contiguous  portions  of  the  mucous  mem- 
brane. It  may  be  primary  or  secondary — /.  c.  it  may  be  due  to  ex- 
tension from  the  trachea,  naso-phaiynx,  mouth,  or  tongue.  The  com- 
monest cause  when  it  is  primary  is  exposure  to  cold  or  dampness. 
Other  causes  are  overstrain  of  the  larynx  in  talking  or  singing,  inhala- 
tion of  irritating  vapors,  dust,  or  smoke,  and  traumatism  either  from 
internal  or  external  injuries. 

It  is  also  caused  by  certain  drugs,  as  iodin  and  mercury,  and  by  con- 
stitutional diseases  in  which  the  system  suffers  greatly,  as  the  exan- 
themata, gout,  rheumatism,  pyemia,  and  erysipelas. 

On  laryngoscopic  examination  the  mucous  membrane  appears  red 
and  swollen,  with  patches  of  mucus  here  and  there,  which  at  first  sight 
may  look  like  pus.  These  patches  appear  particularly  upon  the  vocal 
cords.  In  simple  acute  catarrhal  laryngitis  the  secretion  is  not  pus.  The 
microscope  is  therefore  useful  to  settle  the  diagnosis.  Inflammation 
is  bilateral.  The  congested  membrane  tends  to  occlude  the  passage 
and  so  interfere  with  respiration. 

The  ordinary  form  of  laryngitis  is  not  a  protracted  disease,  two 
weeks  being  rather  an  extreme  limit  and  it  may  last  only  a  few  hours. 
The  circumscribed  form  may  be  only  temporary  or  may  merge  into  the 
chronic  form  of  laryngitis. 


INJURIES  AND  DISEASES   OF  THE  RESPIRATORY  SYSTEM  609 

The  symptoms  vary  from  scarcely  perceptible  uneasiness  to  extreme 
pain,  cough,  hoarseness  or  aphonia,  difificult  deglutition,  dyspnea,  and 
fever. 

If  only  the  larynx  is  invaded,  none  of  these  symptoms,  as  a  rule, 
are  severe,  but  many  times  other  portions  of  the  respiratory  tract  are 
also  inflamed,  and  the  aggregate  symptoms  produce  a  disease  of  great 
severity. 

Diagnosis  may  be  determined  with  tolerable  accuracy  from  the 
symptoms.  If  they  are  at  all  persistent,  a  laryngoscopic  examination 
should  be  made  to  exclude  other  graver  diseases  whose  early  symp- 
toms do  not  differ  noticeably  from  those  of  acute  catarrhal  laryngitis. 

Prognosis. — The  prognosis  in  simple,  uncomplicated  acute  laryngitis 
is  good.  There  is  no  danger  of  extension  to  other  parts  of  the 
respiratory  tract.  Repeated  attacks  at  frequent  intervals  may  predis- 
pose to  the  habit  or  lead  to  chronic  laryngitis.  When  the  disease 
accompanies  a  constitutional  dyscrasia,  it  is  then  a  local  manifestation 
of  a  constitutional  disorder,  and  the  prognosis  depends  upon  that  of  the 
disease.  When  due  to  traumatism  it  depends  upon  the  severity  and 
extent  of  the  lesion  caused  by  the  traumatic  injury.  A  circumscribed 
laryngitis  has,  on  the  whole,  a  less  hopeful  prognosis  than  the  diffused 
form. 

Treatment. — Mild  purgative  hepatic  stimulation  and  restricted  diet 
constitute  a  sufficient  constitutional  treatment  for  most  cases,  since 
many  recover  without  any  medical  treatment  whatever.  External 
applications  of  cold  or  leeches  just  above  the  sternum  may  serve  to 
diminish  the  inflammation.  Mercuric  chlorid  is  an  excellent  drug  in 
this  affection.  Inhalations  of  steam  charged  with  astringent  and  heal- 
ing solutions,  as  balsam  of  tolu,  balsam  of  Peru,  oil  of  pine,  oil  of  tar, 
tincture  of  benzoin,  etc.,  are  excellent  local  remedies.  Applications  of 
astringents  with  brush  or  swab  are  apt  to  be  made  with  some  rudeness 
and  consequent  injury  to  the  mucous  membrane.  They  should  be 
made  with  the  hand-atomizer  instead,  as  rough  treatment  may  bring  on 
an  edema. 

Internal  remedies,  such  as  are  found  in  the  form  of  troches,  are  of 
benefit,  not  because  of  their  local  healing  powers,  but  because  of  their 
constitutional  stimulation  of  the  secretory  function.  Aconite  may  be 
used  for  the  fever. 

The  large  majority  of  cases  of  laryngitis  that  come  under  the  physi- 
cian's care  are  those  of  the  public  speakers  and  singers  whose  voices, 
having  failed  temporarily  from  over-use  or  strain,  must  nevertheless  be 
put  into  good  condition  as  soon  as  possible.  Rest  and  confinement  to 
the  house,  absolute  discontinuance  of  the  use  of  the  voice  even  in  con- 
versation, and  faithful  continuance  of  the  treatment  outlined  above,  will 
effect  the  speedy  cure  hoped  for. 

Bosworth  believes  that  many  cases  of  so-called  acute  laryngitis  are 
really  the  lighting  up  of  an  exciting  chronic  inflammation,  a  sequence 
of  repeated  attacks  of  acute  rhinitis  or  of  naso-pharyngeal  catarrhal 
inflammation.  Accordingly,  he  would  treat  such  inflammations  as 
an  antecedent  measure  and  also  while  treating  the  laryngitis  proper.  He 
advocates  the  rather  free  use  of  cocain  in  this  connection. 

Acute   Infantile   Laryngitis. — In  children  the   mucous    mem- 
39 


6lO  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

brane,  both  above  and  below  the  i^Iotti.s,  is  more  vascular  and  sensitive 
than  is  the  case  with  adults,  and  also  more  richly  supplied  with  glandu- 
lar tissue.  It  is  of  smaller  caliber  also,  so  that  tumefaction  of  the 
mucous  membrane  more  readily  leads  to  stenosis. 

Inflammation  above  the  glottis  is  similar  to  that  of  adults,  except 
that  there  is  a  greater  intensity  of  symptoms,  as  might  be  expected 
from  the  anatomical  differences  just  noted. 

Quiet,  warmth,  restricted  diet,  and  the  same  line  of  treatment  as 
indicated  for  adults,  modified  to  suit  the  age  of  the  little  patient  and 
the  severity  of  the  symptoms,  is  all  that  is  needed,  for,  though  at  times 
alarming,  the  inflammation  above  the  glottis,  if  it  extend  no  farther,  is 
rarely  dangerous. 

Below  the  glottis,  however,  inflammation  takes  on  a  more  serious 
aspect.  Here  lymph-glands  are  numerous,  far  more  so  relatively  than 
in  adults,  and  in  some  there  is  a  special  tendency  to  enlargement  of 
those  structures.  Exposure  to  cold  aggravates  this  tendency,  and  we 
have  the  quickly  supervening  phenomena  of  "  croup."  In  some  adults 
there  lingers,  long  after  the  period  of  childhood  is  passed,  a  croupous 
tendency,  only  explicable  by  the  fact  that  subglottic  lymphatic  tissue 
is  relatively  abundant,  especially  sensitive,  and  subjective  to  inflam- 
matory changes.  Dr.  Francke  H.  Bosworth  maintains  that  in  children 
who  are  subject  to  attacks  of  "  croup  "  there  is  a  chronic  inflammation 
of  this  lymphatic  tissue,  and  that  when  there  is  exposure  to  cold  or 
damp  it  takes  only  a  brief  time  for  this  chronic  inflammation  to 
change  to  an  acute  form  of  great  severity.  The  tissues  become 
greatly  swollen  and  tend  to  occlude  the  upper  air-passages,  hence 
respiration  is  greatly  interfered  with. 

Symptoms. — Paroxysmal  attacks  come  on  usually  at  night,  in  which 
a  severe,  high-pitched  barking  cough  and  a  peculiar  stridulous  inspira- 
tion are  the  characteristic  features.  There  may  be  aphonia,  and  yet 
the  "  croupy  "  cough  due  to  the  irritation  of  the  swollen,  turgid  mem- 
brane just  beneath  the  glottis  may  be  present.  There  are  fever,  flushed 
face,  restlessness,  pain,  and  distress  in  the  throat,  at  which  the  child 
clutches  during  the  spasms. 

During  the  day  there  may  be  almost  entire  remission  of  the  symp- 
toms, but  the  voice  becomes  hoarse  toward  night,  and  there  is  an 
occasional  barking  cough  which  is  suggestive  of  the  paroxysm  that 
will  occur  during  the  night. 

The  presence  of  accumulated  mucus,  still  further  filling  up  the 
clearly  narrowed  lumen  of  the  larynx,  probably  explains  the  nocturnal 
exacerbation  of  the  symptoms.  As  the  disease  progresses  secretion  is 
more  abundant  than  at  first,  and  the  raising  and  expectoration  of  this 
mucus  seems  temporarily  to  mitigate  the  symptom.  Suffocation, 
though  always  seemingly  impending,  rarely  occurs,  and  when  the  dis- 
ease is  fatal  there  are  complications  from  bronchitis  or  pneumonia  as 
a  rule. 

The  disease  runs  its  course  in  from  three  or  four  days  to  two  weeks. 
In  the  cold  damp  days  of  spring  and  autumn,  especially  when  children 
are  allowed  to  play  out  of  doors,  have  wet  feet,  or  wear  damp  clothing, 
recurrent  attacks  may  be  expected. 

A  laryngoscopic  examination,  though  difficult  in  the  case  of  children. 


INJURIES  AND  DISEASES   OF  THE  RESPIRATORY  SYSTEM.   6ll 

should  be  insisted  upon.  The  disease  must  be  differentiated  from  mem- 
branous croup  and  diphtheria.  In  the  early  stages  it  is  at  times 
difficult.  In  diphtheria  there  is  a  membrane  in  the  fauces  and  generally 
marked  constitutional  symptoms.  In  membranous  croup  the  progress 
of  the  disease  is  slower  and  dyspnea  is  not  so  marked  at  first.  Con- 
stitutional symptoms  are  also  less  marked. 

Trcatuic}it. — As  a  prophylactic  measure  a  child  who  betrays  a  pre- 
disposition to  this  disorder  should  not  be  exposed  to  extremes  of 
temperature  nor  to  sudden  changes,  nor  be  allowed  to  remain  in  damp 
clothing,  nor  to  breathe  damp  air.  The  feet  should  be  kept  warm  and 
dry.  Attention  should  be  given  to  the  general  health,  and  a  plain, 
nourishing  diet  should  be  the  only  one  tolerated. 

The  bowels  should  be  made  to  move  freely.  Calomel  or  hydrar- 
gyrum cum  creta,  as  in  other  forms  of  laryngitis,  seems  of  especial 
benefit. 

To  control  spasms  antispasmodics  may  be  administered  internally, 
and  hot  water  should  be  freely  used  externally  in  the  forms  of  fomen- 
tations upon  the  throat,  and  as  baths  into  which  the  child  should  be 
placed  at  intervals  of  four  hours. 

Inhalations  of  chloroform  or  of  amyl  nitrite  or  of  ether  may  be 
necessary  when  prompt  action  is  desirable  during  a  severe  spasm. 
Astringent  sprays,  applied  with  the  atomizer,  should  be  used  at  inter- 
vals, especially  during  the  day,  when  the  child  is  more  tractable  owing 
to  the  absence  of  the  paroxysms. 

Inhalations  of  steam  impregnated  with  healing  and  sedative  drugs 
have  a  good  effect,  and  for  a  like  reason  the  atmosphere  of  the  room 
should  be  kept  moist. 

Sometimes  emesis  is  of  avail  in  relieving  the  larynx,  but  it  is  not 
necessary  to  administer  emetics  for  this  purpose.  Tickling  the  fauces 
will  accomplish  the  same  result  and  not  charge  the  stomach  with  drugs. 
Cough-medicines  and  sleeping-potions  should  be  avoided  if  possible,  so 
that  the  stomach  may  not  be  overtaxed.  Muriate  of  ammonia  favors 
secretion,  and  may  be  given  with  that  end  in  view.  If  respiration  is 
seen  to  become  more  difficult,  a  soft  catheter  may  be  inserted.  If 
suffocation  seems  imminent,  intubation  or  tracheotomy  is  indicated,  but 
is  rarely  necessary  in  an  uncomplicated  case  of  even  severe  subglottic 
lar\mgitis. 

Chronic  I/aryngitis. — Chronic  Catarrhal  Laryngitis. — Cases 
arise  which  cannot  be  traced  to  extension  from  other  structures  or  to 
acute  attacks  of  laryngitis.  Such  may  be  called  primary  or  idiopathic. 
Most  cases  of  chronic  catarrhal  laryngitis  are  secondary  in  their  etiology, 
coming  from  extension  of  inflammation  from  the  nose  or  naso-pharynx. 
Many  forms  of  rhinitis  compel  the  patient  to  breathe  through  the 
mouth,  and  the  air,  being  damp,  cold,  and  unpurified  by  not  passing 
through  the  nasal  chambers,  acts  as  an  irritant  to  the  laryngeal  mucous 
membrane.  Possibly  exposure  to  dust  and  impure  air,  improper  use 
of  the  voice  in  speaking  or  singing,  or  the  continuous  use  of  alcohol 
and  tobacco  may  cause  a  primary  chronic  catarrhal  laryngitis,  and  in 
such  cases  as  cannot  be  traced  to  the  extension  from  the  upper  tract 
the  cause  must  be  found  in  such  conditions  or  in  a  dyscrasia.  This 
disease  is  more  common  in  males  than  in  females,  in  adults  than  in 


6l2  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

children.  The  mucous  membrane  is  thickened,  with  dilated  blood- 
vessels and  hyperplasia  of  tissue.  Sometimes  the  muciparous  glands 
seem  to  be  chiefly  involved,  though  it  is  doubtful  if  inflammation  of 
chronic  character  in  mucous  membrane  is  ever  confined  to  them  alone. 
When  they  are  largely  involved  secretion  is  excessive  and  accompanied 
by  desquamation  of  epithelial  elements.     Erosions  are  the  exception. 

Symptoms. — Noticeable  among  the  symptoms  is  the  altered  quality 
of  voice.  At  first  or  in  mild  cases  this  betrays  itself  only  on  prolonged 
use  of  the  voice  or  in  the  effort  to  sing.  When  singing  is  attempted 
the  patient  is  unable  to  sing  either  clearly  or  to  reach  the  higher  notes 
with  the  accustomed  ease,  if  at  all.  Later,  hoarseness  is  continually 
present.  The  voice  has  a  more  strident  quality  in  the  morning,  becomes 
clearer  as  the  nocturnal  secretion  of  mucus  is  raised,  but  if  much  used 
may  give  out  entirely,  and  the  patient  then  suffers  from  temporary 
aphonia,  and  there  are  pain  and  an  "  aching  "  sensation  if,  forgetting  his 
temporary  disability,  he  attempts  to  make  himself  heard.  There  is 
some  cough  and  a  general  feeling  of  uneasiness  and  discomfort  which 
the  patient  attempts  to  relieve  by  "  clearing  the  throat."  In  ordinary 
chronic  catarrhal  laryngitis  there  is  no  pain,  or  only  transient  pain, 
and  little  secretion,  unless  an  acute  attack  supervenes  upon  the  chronic 
condition  or  there  is  accompanying  bronchitis. 

Diagnosis. — Since  the  disorder  usually  comes  on  gradually  and 
asserts  itself  somewhat  strongly  at  times,  only  to  be  followed  by  ap- 
parent improvement,  and  finally  to  settle  down  into  a  well-marked 
chronic  disease,  the  patient  is  generally  able  to  diagnose  his  own  con- 
dition fairly  well.  With  the  symptoms  detailed  and  a  laryngoscopic 
examination  the  diagnosis  is  clear. 

Prognosis. — This  is  good  as  to  life  ;  as  to  continuance,  it  is  dependent 
upon  the  cause.  If  due  to  extension  from  the  nose,  or  naso-pharynx, 
no  cure  can  be  expected  until  the  morbid  condition  in  these  localities  is 
corrected,  and  treatment  should  be  directed  to  that  end.  If  the  disease 
is  idiopathic,  both  topical  applications  and  constitutional  remedies  are 
needed ;  certainly  the  latter  when  it  is  suspected  that  the  cause  is  some 
fault  in  the  constitution. 

It  is  a  disease  of  indefinite  duration,  and  rarely  if  ever  is  spon- 
taneously cured.  If  not  directly  causative  of  neoplasms,  it  certainly 
paves  the  way  for  their  development  and  furnishes  a  favorable  soil  for 
their  incipient  growth. 

Treatment. — Nasal  respiration  should  be  restored  and  nasal  affec- 
tions corrected  by  the  treatment  therapeutic  and  surgical  detailed  under 
the  Surgery  of  the  Nose  and  Naso-pharynx.  Pure  air,  careful  exercise, 
frequent  baths,  moderate  and  restricted  use  of  the  voice,  careful  atten- 
tion to  the  general  health,  and  rigid  avoidance  of  everything  that  is 
known  to  aggravate  the  disease,  are  of  great  importance  in  this 
affection. 

In  addition,  local  treatment  should  be  employed.  Astringent  sprays 
are  useful  applied  with  an  atomizer,  either  a  hand  bulb-instrument  or  the 
one  with  compressed  air.  One  remedy  will  sometimes  succeed  when 
another  fails,  and,  again,  better  results  are  obtained  by  alternating 
one  with  another.  Silver  nitrate,  a  half-grain  or  more  to  the  ounce ; 
zinc  sulphate,  five  grains  to  the  once ;  ferric  chloride,  three  grains  to 


INJURIES  AND  DISEASES   OF  THE   RESPIRATORY  SYSTEM.   613 

the  ounce,  Monsel's  solution,  ISTTI  to  the  ounce;  copper  sulphate  five 
grains  to  the  ounce ;  alum,  ten  grains  to  the  ounce, — are  all  good. 
Tannic  acid  is  sometimes  used,  also  jaborandi,  to  promote  secretion. 

Instead  of  sprays,  or  along  with  sprays,  inhalation  of  drugs  may  be 
practised.  To  accomplish  this  hot  water  is  impregnated  with  the  drug 
— preferably  an  alkahne — and  the  steam  inhaled  for  several  minutes. 
Opium  may  be  added  to  either  the  spray  or  inhalation  if  there  is  much 
pain.     Cocain  should  be  applied  if  the  membrane  is  hypersensitive. 

Most  surgeons  treat  the  larynx  and  trachea  as  they  do  the  nasal 
cavities  by  means  of  compressed-air  apparatus,  using  a  variety  of 
astringent  and  antiseptic  solutions  according  to  the  demands  of  each 
particular  case. 

Subglottic  chronic  catarrhal  laryngitis  bears  the  same  relation 
to  the  ordinary  chronic  form  that  the  infantile  subglottic  acute  laryn- 
gitis bears  to  the  ordinary  acute  form.  It  is  altogether  a  graver 
affection. 

Chronic  subglottic  laryngitis  is  almost  invariably  the  result  of 
repeated  acute  attacks.  It  tends  to  produce  stenosis  of  the  larynx, 
and  its  gravity  is  proportionate  to  the  amount  of  occlusion.  Gradual 
loss  of  voice,  increasing  dyspnea  and  cough,  are  its  most  distinctive 
symptoms. 

Diagnosis  is  to  be  made  by  laryngoscopic  examination,  when  the 
tissues  below  the  vocal  cords  are  seen  to  be  much  hypertrophied  and 
of  a  pale  grayish  color  with  diminished  secretion.  Only  perichondritis 
is  likely  to  be  confused  with  this.  In  perichondritis  pain  is  more  acute. 
Prognosis  is  doubtful,  depending  upon  the  cause.  It  is  not  very 
favorable  as  to  complete  recovery,  but  it  may  be  possible  to  hold  it 
sufficiently  in  check  to  avoid  the  necessity  of  tracheotomy. 

Treatment. — If  excess  of  lymphatic  tissue  is  plainly  the  cause,  ab- 
sorbents must  be  used  (iodid  of  potassium  or  iodid  of  iron)  in  large 
doses. 

In  many  cases  surgical  interference  is  necessary.  Excessive  tissue 
may  be  cut  away  or  the  galvano-cautery  may  be  developed.  Dilatation 
by  hollow  tubes  is  the  most  rational  and  the  most  generally  successful 
method,  though  absorption  goes  on  slowly  under  pressure  of  this  sort. 
Laryngitis  sicca  is  the  term  applied  to  a  peculiar  form  of  chronic 
laryngitis  in  which  secretion  is  deficient  and  crusts  form  and  adhere  to 
the  mucous  membrane,  as  in  atrophic  rhinitis. 

The  cause  is  obscure.  Since  in  most  cases  it  is  accompanied  by 
atrophic  rhinitis,  both  diseases  are  due  either  to  one  and  the  same 
original  cause  or  the  laiyngitis,  as  maintained  by  some,  is  an  extension 
from  the  rhinitis.  This,  however,  is  usually  difficult  of  demonstration, 
and  it  seems  more  reasonable  to  conclude  that  the  same  cause  is  in 
operation  in  the  system  to  produce  both.  The  crusts  vary  in  color 
according  to  whether  they  are  composed  of  inspissated  mucus  alone 
or  of  mucus  mixed  with  pus  and  blood  from  below  the  glottis.  Some- 
times they  are-  annular,  being  formed  on  the  trachea — sometimes  of 
irregular  shape,  especially  if  found  in  a  ventricle. 

Erosions  are  common  from  the  attachment  of  crusts.  A  consider- 
able quantity  collects  beneath  the  crusts  and  slight  hemorrhages  are 
not  uncommon. 


6 14  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

Symptoms. — Morning  cough  in  the  effort  to  expel  the  crusts  that 
have  formed  during  the  night,  together  with  the  naturally  attendant 
conditions,  dyspnea,  fetid  breath,  and  aphonia,  constitute  a  marked 
group  of  symptoms. 

Irritation  of  the  throat  is  sometimes  excessive,  and  is  made  the 
worse  by  attempts  to  clear  it. 

Laryngoscopy  makes  positive  the  diagnosis. 

Trcatiiioit. — Removal  of  crusts,  cleansing  of  the  underlying  surface, 
and  stimulation  of  the  membrane  are  the  indications. 

To  effect  removal  the  crusts  are  first  softened  with  some  solution 
from  the  atomizer,  and  then  gently  removed  with  swab  or  brush  or  fine 
instrument.  After  this  is  done  all  pus  should  be  removed  and  all 
bleeding  stopped.  Silver  nitrate  is  one  of  the  best  substances  for  appli- 
cation to  the  membrane.  Any  of  the  astringents  mentioned  in  the 
Treatment  of  Chronic  Catarrhal  Laryngitis  may  be  employed. 

Chorditis  tuberosa  (trachoma  of  the  larynx  ;  Singer's  node)  is  a 
variety  of  chronic  laryngitis  first  recognized  and  described  by  Tuerch. 
It  consists  of  a  small  white  tumor  upon  one  or  both  vocal  cords,  more 
commonly,  it  is  said,  upon  the  left  one,  situated  at  the  junction  of  the 
anterior  and  middle  thirds  of  the  cord.  It  is  due  to  an  extreme  effort 
to  reach  the  highest  notes  in  singing  where  there  is  already  a  condition 
of  chronic  laryngitis.  It  does  not  increase  in  size  after  its  first  appear- 
ance. It  produces  hoarseness  even  in  conversation,  and  makes  the  use 
of  the  voice  in  singing  an  impossibility.  It  is  readily  seen  on  laryngo- 
scopic  examination. 

It  may  be  removed  by  the  application  of  silver  nitrate  or  by  the  use 
of  the  galvanic  cautery.  In  any  case  the  use  of  the  voice  should  be 
interdicted,  even  in  conversation,  and  both  the  chronic  laryngitis  and 
the  general  health  should  be  treated. 

Diphtheritic  laryngitis,  as  a  rule,  results  from  extension  of  the 
disease  from  the  fauces.  It  belongs  more  properly  to  the  domain  of 
the  general  practitioner  of  medicine,  and  becomes  of  interest  from  a 
surgical  point  of  view  only  when  intubation  or  tracheotomy  is  to  be 
performed.  The  operation  will  be  described  in  its  proper  connection, 
for  it  is  called  for  in  a  variety  of  crises,  not  in  diphtheria  only. 

^detna  of  the  larynx  by  an  earlier  nomenclature  was  known  as 
edema  of  the  glottis,  but,  as  it  is  the  larynx  chiefly,  and  not  the 
rima  glottidis  that  is  involved,  the  modern  requirement  of  making  the 
name  of  the  disease  describe  both  its  position  and  character  brings 
about  a  rejection  of  the  older  term.  It  may  be  either  acute  or  chronic. 
By  the  term  is  meant  an  infiltration  of  the  submucous  connective  tissue 
of  the  larynx  or  of  the  epiglottis  on  either  or  both  surfaces.  It  may 
be  a  true  edema,  a  "  hydrops  "  resulting  from  venous  congestion.  The 
constituents  of  the  infiltrating  fluid  may  be  serum,  lymph,  pus,  or  blood 
in  any  combination,  and  it  may  accumulate  slowly  or  be  practically 
instantaneous  in  its  manifestations,  especially  when  due  to  traumatism. 

When  the  lesion  is  of  inflammatory  origin,  the  inflammation  is  very 
acute,  and  extends  deeply  below  the  mucous  surface  into  the  cellular 
connective  tissue — really  a  cellulitis  or  phlegmonous  laryngitis. 

Exposure  to  cold  and  moisture  is  the  commonest  cause,  though  it 
may  possibly  be  due  to  over-use  of  the  voice,  but  probably  in  that  case 


INJURIES  AND   DISEASES   OF   THE   RESPIRATORY  SYSTEM.   615 

there  is  a  preceding  laryngitis  of  mild  type  of  which  the  patient  is 
unaware.  It  may  follow  the  passage  of  foreign  bodies  into  the  larynx, 
especially  if  the  intruder  is  of  such  a  character  as  to  lacerate  the  tis- 
sues. It  often  occurs  after  extremely  cold  or  hot  or  caustic  liquids 
have  been  swallowed.  It  accompanies  or  follows  many  acute  systemic 
disorders,  in  many  cases  hindering  coalescence.  Slight  exposure  to 
drafts  or  cold,  especially  damp  cold,  is  then  the  exciting  cause  in  a 
system  already  debilitated  by  disease,  as  scarlet  fever,  typhoid,  ery- 
sipelas, gout,  measles,  diphtheria,  croup,  quinsy,  nephritis,  pneumonia, 
bronchitis,  or  affections  of  the  tongue  and  throat.  Septicemia  is  said 
to  furnish  conditions  especially  favorable  to  its  development.  Clumsy 
operations  upon  the  larynx  or  the  inevitable  contusion  and  laceration 
attending  the  removal  of  neoplasms  may  cause  it.  Men  are  more  prone 
to  edema  of  the  larynx  than  women,  because  of  their  greater  exposure 
to  cold  and  dampness. 

The  non-infiammatory  form  of  edema  is  due  to  causes  not  within 
the  larynx  itself;  the  cause  is  to  be  sought  for  in  conditions  predis- 
posing to  dropsy  in  other  parts  of  the  body.  Whatever  prevents  normal 
venous  return,  as  renal,  cardiac,  and  hepatic  disorders,  may  cause  it, 
especially  if  there  is  a  morbid  condition  of  the  mucous  membrane,  as 
relaxation  or  chronic  inflammation. 

The  epiglottis,  especially  the  posterior  surface,  the  epiglottic  folds, 
and  the  ventricular  bands  are  the  portions  most  commonly  infiltrated, 
the  vocal  cords  and  the  subglottic  portions  suffering  only  rarely.  The 
swellings  are  tense,  hard,  with  some  fluctuation  under  the  touch  of  the 
finger,  and  in  severe  cases  portions  of  the  enlarged  masses  may  be  seen 
on  depressing  the  tongue. 

Synnptouis. — At  times  the  edema  comes  on  so  suddenly  that  death 
ensues  before  relief  can  be  summoned.  In  such  cases  there  may  be 
spasms  of  the  constrictors  of  the  glottis  or  paralysis  of  its  dilators,  or 
the  condition  may  have  been  present  for  some  time,  and  some  untoward 
movement  of  the  parts,  as  a  cough  or  hasty  inspiration,  may  have  in- 
creased it  or  so  changed  the  position  of  some  portion  of  tissue  as  to 
occlude  the  opening. 

In  the  edema  of  venous  congestion  the  suddenness  of  the  onset  is 
more  marked,  and  the  premonitory  symptoms  less  so  than  in  the 
phlegmonous  type. 

In  the  phlegmonous  variety  there  are  no  pyrexia,  discomfort,  and 
increasing  distress  in  the  throat,  and  the  symptoms  are  all  developed 
within  twenty-four  hours. 

Pyrexia  is  absent  in  the  serous  edema  of  venous  congestion,  and 
pain  is  not  so  marked  as  in  the  inflammatory  form.  In  both  there  are 
increasing  dyspnea,  stridulous  breathing,  dysphagia,  and  restlessness. 
The  face  is  anxious.  Sleep  is  impossible  from  the  fear  of  suffocation. 
In  acute  edema  all  these  symptoms  manifest  themselves  in  intense 
paroxysms  when  the  disease  is  fairly  present.  The  patient  may  die  in 
the  first  paroxysm  or  the  paroxysms  may  increase  in  severity,  with 
cyanosis,  protruding  eyeballs  and  tongue,  and  rapid  pulse,  until  a  fatal 
issue  is  reached. 

In  chronic  edema  the  symptoms  steadily  increase  in  severity.  The 
paroxysms  are  followed  by  temporary  reHef,  but  gradually  grow  more 


6l6  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

severe  and  frequent.    Excitement  may  renew  the  paroxysms  when  they 
have  apparently  been  quieted. 

The  diagnosis  indicated  by  the  symptoms  is  confirmed  by  the 
laryngoscope. 

Prog)iosis. — Suffocation  is  the  one  great  danger.  As  has  been  said, 
it  may  occur  instantaneously  at  the  first  or  any  succeeding  paroxysm. 
Or  apnea  may  come  on  gradually  from  the  insufficient  oxidation  of  the 
blood.  Unrelieved,  an  acute  case  will  increase  in  the  severity  of  its 
symptoms,  go  on  from  bad  to  worse,  and  terminate  fatally,  ending  in 
coma,  generally  in  three  or  four  days. 

Chronic  edema  is  not  the  less  dangerous  because  its  development  is 
slower.  Since  its  causes  are  likely  to  be  of  long  duration,  if  not  in- 
curable, there  is  slight  hope  of  recovery  from  chronic  edema.  What 
would  be  a  trifling  edema  in  other  parts  of  the  body  is  here  sufficient 
to  threaten  life,  and  it  is  often  necessary  to  resort  to  tracheotomy  as  a 
means  of  relief  and  to  take  away  the  element  of  danger  while  the 
general  condition  is  under  treatment. 

Deuteropathic  cases,  provided  means  are  taken  to  relieve  immediate 
danger,  must  depend  upon  the  disease  accompanying  or  causing  them. 
Edema  below  the  glottis  is  less  favorable  than  that  above. 

Treatment. — Depletion  of  the  infiltrated  tissue  by  any  and  all  means 
is  here  the  indication.  Free  puncture  and  incision  or  scarification  by  a 
laryngeal  knife  or  by  ordinary  lancet  or  curved  bistouiy  covered  with 
thread  or  court-plaster  almost  to  the  point  affords  immediate  outlet  to 
the  accumulated  fluid.  This  may  be  repeated  in  six  or  eight  hours  if 
necessary.  The  laryngoscope  should  be  used  if  possible ;  if  not,  the 
knife  must  be  guided  by  the  finger.  The  cuts  must  be  as  far  away 
from  the  median  line  as  possible,  so  as  not  to  complicate  an  already 
bad  condition  by  the  entrance  of  fluid  into  the  air-passages.  Gargling 
with  warm  water  or  inhalation  of  steam  causes  relaxation  or  dilatation 
of  blood-vessels,  so  that  hemorrhage  is  more  free.  If  this  fails  to  give 
relief,  tracheotomy  should  be  performed  at  once.  In  severe  cases  it  is 
used  as  a  precautionary  measure,  for  edema  is  so  treacherous  a  disease 
that  suffocative  apnea  has  often  been  known  to  take  place  after  the 
departure  of  the  surgeon  and  before  he  could  be  recalled.  The  sur- 
geon must  also  bear  in  mind  the  fact  that  congestion  of  the  brain  or 
lungs  may  occur,  and  even  after  a  fair  degree  of  respiration  has  been 
restored  the  patient  may  die  from  suboxidation.  In  country  practice, 
where  the  surgeon  can  see  his  patient  only  at  long  intervals,  these  are 
considerations  not  to  be  neglected.  Tracheotomy  rather  than  laryn- 
gotomy  is  to  be  performed,  as  better  meeting  the  possible  complications. 

Intubation  is  practically  out  of  the  question  in  these  cases,  for,  if  the 
difficulties  of  insertion  are  happily  overcome,  retention  is  almost  im- 
possible because  of  the  swelling  and  distortion.  In  moderate  cases  a 
catheter  might  possibly  be  retained.  Spontaneous  subsidence  is  not 
unknown.  In  edema  from  nervous  congestion  and  in  chronic  edema 
from  any  cause,  in  addition  to  the  above  line  of  treatment  the  cause 
must  be  treated  and  systemic  depletion  of  the  infiltrated  tissues  be 
resorted  to  by  catharsis,  diaphoresis,  and  diuresis. 

Edema  of  the  larynx  from  causes  that  produce  anasarca  is  practi- 
cally incurable,  so  that  the  treatment  can  only  be  palliative. 


INJURIES  AND   DISEASES   OF   THE   RESPIRATORY  SYSTEM.   617 

Abscess  of  the  I/arynx. — This  affection  may  be  intra-laryngeal 
or  peri-laiyngeal.  It  may  be  primary  or  secondary,  but  is  usually  the 
latter,  being  commonly  secondary  to  perichondritis,  phlegmonous 
laryngitis,  or  acute  diseases,  among  which  are  enteric  fever,  typhus 
fever,  the  exanthemata,  small-pox,  diphtheria,  pyemia,  tuberculosis, 
syphilis,  and  glanders.  Traumatism,  especially  that  due  to  the  entrance 
of  foreign  bodies,  is  a  cause,  and  when  this  is  so  the  location  of  the 
abscess  is  determined  by  the  place  of  the  injury.  When  due  to  sys- 
temic diseases  it  shows  a  preference  for  the  cartilages  in  the  following 
order :  the  inferior  surface  of  the  epiglottis,  the  internal  surface  of  an 
arytenoid  cartilage,  and  the  ventricular  bands. 

The  abscess  may  "  point "  externally  or  internally  ;  only  rarely  does 
an  internal  abscess  point  externally.  The  external  may  find  an  outlet 
on  the  cutaneous  surface,  even  by  a  somewhat  extended  fistulous  track, 
although  when  it  is  a  retro-pharyngeal  abscess  it  naturally  "  points  " 
into  the  pharynx. 

Symptoms. — There  are  pain,  aphonia  or  dysphonia,  dysphagia, 
dyspnea,  and  cough.  When  peri-laryngeal  on  the  anterior  or  lateral 
aspect  of  the  larynx,  a  tumefaction  is  often  visible  on  inspection  and 
palpation,  with  pain,  tenderness,  and  fluctuation  on  pressure.  When  it 
is  retro-pharyngeal  deglutition  may  become  impossible  from  the  pain 
that  the  attempt  induces.  Dyspnea  may  be  extreme  and  suffocation 
imminent,  either  from  the  large  size  and  amount  of  occlusion  or  from 
the  contraction  and  paralysis  of  muscles  in  neurotic  patients. 

Diagnosis  of  the  intra-laryngeal  variety  is  by  the  laryngoscope.  A 
tumor  presents,  red  and  angry  at  the  base,  with  a  yellowish  apex, 
though  the  accompanying  inflammation  of  the  mucous  membrane  may 
tend  to  conceal  the  abscess  ;  it  must  then  be  diagnosed  by  circum- 
scribed sensitiveness  of  the  membrane.  Peri-laryngeal  abscess  is 
diagnosed  by  the  physical  signs. 

Prognosis  is  favorable  unless  it  is  a  sequel  or  complication  of  ex- 
hausting diseases,  and  then  it  depends  upon  them.  Precautionary 
tracheotomy  will  remove  danger  of  suffocation,  and  if  the  system 
recovers  only  slowly,  the  opening  should  be  maintained  for  a  short 
time,  as  under  such  circumstances  there  may  be  a  succession  of  laryn- 
geal abscesses.  After  one  abscess,  and  especially  after  several,  stenosis 
may  result,  but  it  is  rare. 

Treatment. — Spontaneous  discharge  with  immediate  relief  is  not 
unknown,  but  should  not  be  waited  for.  Once  diagnosed,  an  intra- 
laryngeal  abscess  should  be  incised,  either  with  the  laryngeal  knife  or 
a  curved  bistoury  protected  to  within  a  short  distance  of  the  end.  If, 
for  any  reason,  the  surgeon  cannot  reach  it,  tracheotomy  presents  the 
only  safe  course.  Peri-laryngeal  abscesses  are  opened  at  the  most 
prominent  point. 

Chondritis  and  Perichondritis. — Chondritis  is  invariably  second- 
ary to  perichondritis,  and  the  latter  is  almost  as  invariably  a  secondary 
disease,  although  a  primary  form  due  to  protracted  exposure  to  cold 
and  moisture,  especially  when  the  voice  is  much  used  at  the  same  time, 
is  not  unknown.  Perichondritis  is  essentially  also  an  acute  disorder. 
Other  causes  than  cold  arc — traumatism,  typhoid  fever  (which  seems 
especially  prone  to  bring  on  acute  inflammation  of  the  perichondrium). 


6l8  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

the  exanthemata,  diphtheria,  pneumonia,  erysipelas,  tuberculosis,  ma- 
lignant disease,  and  syphilis.  Men  are  more  subject  than  women, 
adults  than  children,  probably  from  the  greater  frequency  of  the  ex- 
posure. Between  twenty-five  and  forty  is  the  period  most  apt  to  suffer 
from  this  disease. 

The  pathological  changes  are  inflammation,  with  occasionally  great 
tumefaction.  If  there  is  pus,  the  perichondrium  separates  from  the 
cartilage,  and  the  latter  then  undergoes  necrosis ;  as  a  rule,  and  some- 
what tardily,  sloughs  are  removed.  Usually  one  cartilage  only  is 
involved,  especially  at  first,  but  they  may  all  be  affected  together  or 
successively.  The  arytenoid  cartilages  are  liable  to  become  separated 
from  their  attachment  and  be  discharged  en  masse,  though  the  affection 
is  apt   to  be  unilateral. 

The  cricoid  is  affected  most  frequently  on  the  posterior  portion, 
causing  destructive  and  painful  deglutition. 

Perichondritis  of  the  thyroid  is  usually  unilateral  on  the  inner  sur- 
face, though  no  part  is  wholly  exempt  from  possible  implication. 

Perichondritis  of  the  epiglottis  is  invariably  a  secondary  affection, 
and  generally  occurs  in  syphilis,  advanced  stages  of  tuberculosis,  and 
carcinoma,  and  is  then  an  ulcerative  form  of  the  disease. 

Syuiptouis. — These  vary  with  the  location  and  intensity  of  the 
affection,  but  there  are  present  the  usual  signs  of  suppurative  disease 
and  chills,  or  occasionally  marked  rigors  and  fever  (ioo°-i02°  F.), 
general  pains  in  the  muscles  and  bones,  loss  of  appetite,  and  occa- 
sionally slight  nausea. 

The  symptoms  of  acute  laryngitis  quickly  assert  themselves,  accom- 
panied by  an  acute  sensation  or  a  localized  soreness  not  common  to 
simple  laryngitis.  There  is  sometimes  pain  during  phonation  and 
deglutition,  and  it  is  said  to  be  more  severe  when  the  abscess  is  caused 
by  syphilis  than  when  caused  by  other  diseases. 

Hoarseness  is  followed  by  loss  of  voice,  respiration  becomes  difficult 
and  stridulous,  and  apnea  threatens.  Cough  is  not  a  very  common 
symptom  until  the  abscess  begins  to  discharge  pus  or  fragments  of 
necrosed  cartilage. 

Diagnosis. — The  laryngoscope,  in  addition  to  subjective  symptoms, 
is  all-important  here  when  the  interior  aspect  of  the  cartilages  is  in- 
volved, and  physical  signs,  together  with  subjective  symptoms,  are 
sufficient  when  the  external  surfaces  are  affected. 

A  cricoid  perichondritis  produces  irregular  tumefaction  beneath  the 
vocal  cords,  usually  at  the  back,  but  sometimes  laterally,  and  pushes  up 
toward  the  surface  of  this  space,  tending  to  occlude  it. 

Upon  the  arytenoid  cartilage  the  perichondritis  limits  movement,  and 
may  make  an  ankylosis  between  the  cricoid  and  itself,  and  is  usually 
unilateral,  tending  to  press  backward  toward  the  esophagus. 

The  symptoms  of  chills,  fever,  and  general  malaise,  with  sore  throat, 
may  at  first  confuse  the  diagnosis,  since  phlegmonous  laryngitis  and 
croupous  laryngitis  begin  somewhat  similarly. 

In  both  of  these  diseases,  however,  the  fever  runs  higher  than  in 
perichondritis — up  to  104°  F.  at  times — while  in  perichondritis  it  rarely 
reaches  102°  F.  In  croupous  diseases  the  peculiar  cough  is  present  and 
the  tumefaction  is  more  nearly  annular.    In  phlegmonous  laryngitis  the 


INJURIES  AND   DISEASES   OF   THE   RESPIRATORY  SYSTEM.   619 

inflammation  and  tumefaction  are  uniform,  and  may  be  almost  wholly 
above  the  larynx.     New  growths  are  without  acute  inflammation. 

Prognosis. — Those  cases  of  perichondritis  that  are  caused  by  expo- 
sure to  cold  and  dampness  or  by  traumatism  are  of  favorable  prognosis. 
Those  caused  by  tuberculosis  or  malignant  disease  or  other  progressive 
disorders,  and  in  which  all  the  cartilages  are  successively  involved, 
rarely  recover. 

When  perichondritis  is  caused  by  the  more  acute  diseases,  complete 
recovery  may  occur  with  resolution  of  the  disease.  But  quite  likely, 
as  has  been  seen,  extensive  necrosis  of  cartilage  may  ensue,  with  con- 
sequent deformity,  stricture,  and  stenosis — conditions  that  must  be  met 
as  they  arise. 

Treatment. — At  first  measures  must  be  taken  to  check  inflammation 
and  promote  absorption.  Leiter's  coils  and  ice  applied  externally, 
together  with  the  swallowing  of  ice,  are  all  of  great  value  here. 
Among  absorbents,  mercury  or  iodin  may  be  applied  as  an  ointment, 
and  solution  of  iodin  may  be  applied  internally. 

The  bowels  must  be  kept  open,  and  the  cause  may  be  treated  if  it 
is  acute  or  systemic  disease.  Tonics  and  stimulants  are  often  indicated. 
Severe  pain  may  be  relieved  by  injections  of  morphin  or  by  the  appli- 
cation of  cocain  to  the  laryngeal  mucous  membrane.  Syphilis  should 
receive  specific  treatment. 

Laryngotomy  should  be  performed  if  obstruction  threatens,  and  is 
better  than  tracheotomy  for  the  removal  later  of  the  necrosed  portions 
of  cartilage. 

In  many  cases  bougies  or  other  dilators  have  to  be  used  for  a  long 
time  to  overcome  stenosis,  and  in  others  tracheal  tubes  have  to  be  per- 
manently worn.     Plastic  operations  are  not  successful. 

Ulcers  of  the  I/arynx. — Ulceration  of  the  larynx  may  simply 
affect  the  mucous  membrane  or  it  may  be  the  result  of  the  breaking 
down  of  tumors,  either  benign  or  malignant,  or  of  those  of  tubercular 
or  syphilitic  origin. 

A  chronic  inflammation  of  the  laryngeal  mucous  membrane  predis- 
poses to  ulceration,  as  in  other  mucous  surfaces,  but  the  process  is  not 
at  all  distinctive.  The  ulcers  may  be  slight  erosions  due  to  traumatism 
or  to  desquamation  of  epithelium  in  a  condition  of  low  vitality,  or  they 
may  have  considerable  depth  if  the  cause  and  condition  of  the  mem- 
brane both  persist.  Such  ulcers  often  exist  quite  commonly  upon  the 
vocal  cords  without  the  knowledge  of  the  patient,  and  are  regarded 
simply  as  a  manifestation  of  the  chronic  process  under  circumstances 
more  or  less  tending  to  aggravate  it.  Stimulation  of  the  surfaces  and 
edges  with  nitrate  of  silver,  with  general  treatment  of  the  chronic  lar- 
yngitis, is  the  treatment.  Rest  and  non-use  of  the  voice  often  effect  a 
cure  without  therapeutic  interference. 

Tuberculosis  of  the  I/arynx. — Without  doubt,  in  the  majority 
of  cases  tuberculosis  of  the  larynx  is  secondary  to  pulmonary  disease, 
yet  there  is  no  reason  why  its  first  area  of  invasion  may  not  be  there, 
since  the  tubercle  bacillus  may  find  primary  lodgement  in  any  part  of 
the  body.  In  fact,  we  may  go  farther,  and  declare  that  a  process  of 
reasoning,  unsupported  by  clinical  facts,  might  lead  us  to  the  conclusion 
that  the  larynx  from  its  anatomical  position  is  particularly  exposed  to 


620  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

primary  invasion  by  the  tubercle  bacillus.  But,  clinically,  it  is  found 
that  in  many  cases  pulmonary  tuberculosis  goes  on  to  the  fatal  end 
without  invasion  of  the  larynx  at  all,  or  it  occurs  very  late  in  the  his- 
tory of  the  disease ;  and  further  that  laryngeal  tuberculosis  unaccom- 
panied by  pulmonary  lesions  is  so  rare  as  to  be  practically  unrecog- 
nized. When  laryngeal  tuberculosis  has  been  believed  to  exist  alone, 
it  has  been  followed  so  promptly  by  signs  of  the  disease  in  the  lungs 
that  the  conclusion  was  almost  inevitable  that  it  was  present  before  or 
simultaneously  with  the  affection  in  the  larynx.  In  any  event,  the 
existence  of  the  disease  in  the  larynx  affords  the  strongest  probability 
of  its  speedy  migration  to  the  lungs,  though  of  course  this  is  not  a 
demonstrable  certainty. 

Since  the  sputum  charged  with  the  bacillus  is  constantly  passing 
over  the  mucous  membrane  of  the  larynx,  it  needs  only  the  presence 
of  an  erosion  to  effect  inoculation,  and  no  doubt  such  is  the  clinical 
history  of  the  great  majority  of  cases  of  tuberculous  disease  of  the 
larynx.  The  generally  lowered  tone  of  health  and  the  tendency  to 
"  catch  cold  "  lead  to  a  condition  of  the  mucous  membrane  especially 
favorable  for  the  development  of  micro-organisms. 

The  disease  is  most  common  in  male  adults  between  twenty  and 
forty  years  of  age. 

Pathology. — If  the  larynx  come  under  observation  during  the  incip- 
ient stages,  it  is  seen  to  be  anemic  and  paler  than  normal.  Later  there 
is  thickening  of  the  mucous  membrane  from  tubercular  infiltration. 

Tuberculosis  of  the  larynx  generally  shows  first  at  the  arytenoid 
cartilage  or  commissure,  and  later  the  aryepiglottic  folds.  It  invades 
the  ventricular  and  the  vocal  bands  and  the  epiglottis  in  the  order 
named,  but  all  parts  are  subject  to  it.  At  first  it  may  be  unilateral, 
but  as  the  disease  advances  both  sides  are  involved,  particularly  in  the 
lymph-glands,  with  great  deformity.  As  the  tumefaction  progresses 
small  yellowish  points  appear  studding  the  mucosa,  but  the  integrity 
of  the  epithelium  is  not  at  first  impaired.  Later,  each  of  these  yellow- 
ish points  becomes  the  seat  of  ulceration.  These  diminutive  ulcers  by 
increasing  in  size  coalesce,  and  ulcers  of  larger  and  larger  size  are 
formed  until  the  membrane  is  almost  one  continuous  ulcer.  It  is  of  a 
grayish-yellow  color,  not  depressed,  not  differing  markedly  in  color 
from  the  anemic  infiltrated  mucous  membrane  at  its  edges.  Secretion 
is  somewhat  scant  and  of  a  thick,  ropy  consistency,  with  a  relatively 
large  amount  of  mucus  compared  with  pus,  and  charged  with  the 
tubercle  bacillus.  Infiltration  is  always  extensive,  and  prevents  the 
loss  of  tissue  which  is  really  going  on  from  the  surface  of  the  ulcer 
from  becoming  prominently  manifest.  Though  beginning  in  the 
mucosa,  the  infiltration  deepens,  and  perichondritis  with  consequent 
chondritis  is  not  uncommon.  Necrosis  occurs  as  in  perichondritis 
due  to  other  causes ;  the  arytenoid  cartilages  also  may  be  discharged 
entire  or  in  part ;  on  the  other  hand,  there  may  be  ankylosis  of  the 
crico-arytenoid  joint.  Edema  may  really  be  present,  but  more  fre- 
quently the  excessive  tubercular  infiltration  simulates  the  edematous 
condition. 

Symptoms. — One  of  the  earliest  symptoms,  and  the  one  which  per- 
haps first  draws  attention  to  the  disease,  is  loss  of  voice.     Infiltration 


INJURIES  AND  DISEASES   OF  THE  RESPIRATORY  SYSTEM.   62 1 

at  the  commissure  prevents  approximation  of  the  vocal  cords,  and  the 
voice  is  wholly  gone  at  once.  In  others,  where  the  disease  commences 
elsewhere  or  is  only  slight,  there  is  hoarseness,  followed  by  a  weak 
voice  which  gradually  merges  into  aphonia.  When  the  tubercular 
infiltration  is  higher  the  voice  may  not  be  lost,  but  this  is  rare. 

There  is  excessive  sensitiveness  of  the  parts,  and  pain  is  early,  severe, 
and  lasting,  particularly  when  the  epiglottis  is  invaded.  Food  passing 
over  renders  deglutition  almost  impossible,  and  an  already  grave  con- 
dition is  rendered  more  so  by  the  diminished  nourishment.  When 
destruction  of  tissue  has  gone  to  a  considerable  extent  the  case  is 
complicated  by  the  passage  of  food  into  the  larynx  or  posterior  nares. 
Cough  is  an  ordinary  concomitant  of  the  pulmonary  lesion,  but  is  in- 
creased and  is  much  more  painful  after  the  involvement  of  the  larynx. 

Dyspnea  is  not  especially  characteristic  of  the  disease,  though  it 
may  be  present.  Hemorrhage  in  large  amount  never  comes  from  the 
larynx.  The  laity  are  apt  to  feel  that  laryngeal  disease  is  especially 
serious,  and  the  patient  frequently  betrays  his  anxiety  in  his  face. 

Diagnosis. — The  almost  invariable  existence  of  pronounced  pul- 
monary tuberculosis  renders  the  probability  exceedingly  strong  that 
ulceration  in  the  larynx  would  be  of  the  same  origin.  However,  ulcers 
of  syphilitic  origin  may  exist  along  with  tubercular  disease,  so  that  a 
differential  diagnosis  must  be  made.  Tuberculosis  of  the  larynx  is 
also  to  be  differentiated  from  malignant  disease. 

Syphilitic  ulcers  are  round  in  shape,  excavated,  and  have  an  areola 
of  reddish  color.  There  are  usually  other  indications  of  the  disease  in 
the   system. 

In  malignant  disease  the  ulceration  is  unilateral,  irregular  in  outline, 
and  nodular ;  there  are  profuse  ulceration  and  much  destruction  of 
tissue,  and  the  characteristic  cachexia  is  usually  present.  Micro- 
scopical examination  of  the  sputum  is  employed  to  establish  a  doubtful 
diagnosis. 

Prognosis. — This  is  exceedingly  grave  as  to  life,  inasmuch  as  it 
usually  complicates  an  existing  condition  already  serious  in  itself 

If  the  disease  were  actually  primar>^  and  seen  in  its  early  stages,  it 
might  no  doubt  be  wholly  arrested,  but  practically  this  never  happens. 
Its  course  may  be  checked  and  the  patient  rendered  more  comfortable. 
According  to  the  statistics  of  Bosworth,  it  shortens  life  on  the  average 
one  year.  The  average  duration  of  pulmonary  tuberculosis  being  three 
years,  a  patient  will  probably  live  one  year  and  six  months  after  the 
appearance  of  the  disease  in  the  larynx. 

Treatment. — Assuming  that  constitutional  treatment,  both  medicinal 
and  dietetic,  would  already  be  in  progress,  we  need  here  consider  only 
the  local  measures  suitable  for  tuberculous  ulceration  in  a  locality  so 
easily  accessible  as  the  larynx. 

Cleansing  should  be  thorough.  This  is  accomplished  by  an  alkaline 
spray  thrown  upon  the  part,  as  Dobell's  solution,  or  boric-acid  solution, 
or  a  solution  of  peroxid  of  hydrogen.  Astringents  may  then  be  ap- 
plied, as  nitrate  of  silver,  sulphate  of  zinc,  or  tannin  in  glycerin. 

Pain,  which  is  always  persistent  and  often  severe,  may  be  controlled 
by  solutions  containing  morphin.  Cocain  should  be  used  with  care, 
as  absorption  takes  place  rapidly  ;  deglutition  will  be  easier  and  nutri- 


622  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

tion  will  be  better  maintained  if  its  application  be  made  before  food  is 
taken. 

Iodoform  or  aristol  or  boric  acid  should  be  dusted  on  the  parts  after 
the  cleansing.  The  odor  of  iodoform  is  so  extremely  disa<^reeable  that 
europhen  in  solution  may  take  its  place. 

Lactic  acid  is  a  time-honored  remedy.  Menthol  in  olive  oil  is  men- 
tioned by  some  authors. 

Medicated  inhalations  often  afford  marked  relief  to  the  parts,  but 
their  curative  qualities  are  very  small. 

Regular  treatment,  as  indicated  above,  should  be  given  two  or  three 
times  a  week. 

Tracheotomy  may  be  necessary  if  there  is  an  edematous  infiltration. 
It  has  even  been  advocated  as  a  curative  measure,  its  value  being  the 
rest  afforded  to  the  larynx  and  in  the  greater  amount  of  oxygen 
thereby  furnished  to  the  system.  At  best,  it  may  render  the  patient 
more  comfortable  and  possibly  somewhat  prolong  his  life,  but  is  certain 
to  impress  him  with  the  progressive  and  hopeless  character  of  the 
disease. 

Syphilis  of  the  I/arynx. — Syphilitic  disease  of  the  larynx  occurs 
both  in  the  secondary  and  tertiary  stages,  and  in  general  it  may  be  said 
its  manifestations  in  either  stage  are  identical  with  those  in  the  nasal  or 
buccal  mucous  membrane,  modified  only  by  the  anatomical  situation. 
Following  the  cutaneous  eruptions  of  the  secondary  stage  is  at  times  an 
erythema  of  the  mucous  membrane  of  the  larynx.  Mucous  patches 
are  somewhat  common  manifestations  of  the  secondary  stage,  but  are 
frequently  the  first  evidence  of  the  disease  in  the  larynx.  They  may 
appear  on  the  vocal  cords,  the  epiglottis,  the  arytenoids,  and  the  ven- 
tricular bands,  and  may  be  few  or  many,  the  symptoms  depending  upon 
the  location.  Ulceration  is  a  late  manifestation  of  the  secondary  stage, 
but  is  a  constant  lesion  in  the  tertiary.  It  is  symmetrical  and  bilateral, 
and  is  either  superficial  or  deep.  The  superficial  ulcers  may  almost  be 
said  to  mark  the  border-line  between  the  secondary  and  tertiary  stages, 
while  deep,  destructive  ulcerations  are  the  inevitable  result  of  the 
unchecked  progress  of  the  disease  in  the  tertiary  stage. 

Gummata  characterize  the  tertiary  stage,  and  their  natural  termina- 
tion is  ulceration. 

The  superficial  ulcer,  but  slightly  depressed  below  the  surface,  is 
rounded  or  ovoid  in  form,  has  no  areola,  and  secretes  a  yellowish  pus. 
The  amount  of  necrotic  tissue  is  relatively  small. 

The  deep  ulcer  results  from  the  breaking  down  of  the  gummy  tumor. 
It  is,  as  a  rule,  a  rapid  process,  and  the  amount  of  necrotic  tissue  dis- 
charged is  relatively  large.  It  generally  invades  the  perichondrium, 
setting  up  a  perichondritis  with  chrondritis,  resulting  in  necrosis  of 
cartilage.  The  arytenoid  cartilages  are  apt  to  be  first  attacked,  and 
may  be  wholly  destroyed.  The  cricoid,  the  thyroid,  and  lastly,  the 
epiglottis,  are  attacked  in  the  order  named.  In  the  fibro-cartilage  of 
the  epiglottis  the  process  of  destruction  is  more  like  constant  erosion 
than  is  the  case  with  true  cartilaginous  structures,  where  a  sequestrum 
is  formed  which  may  slough  as  soon  as  fully  detached,  or  may  remain 
in  situ  indefinitely  or  until  destruction  of  all  surrounding  tissue  sets  it 
free. 


INJURIES  AND  DISEASES   OF  THE   RESPIRATORY  SYSTEM.  623 

Symptoms. — Impairment  of  voice  in  all  degrees  is  a  marked  symp- 
tom, depending  for  its  extent  upon  the  location  of  the  lesions.  Dys- 
phagia is  another  symptom,  particularly  if  the  posterior  portion  of  the 
cricoid  is  involved  or  the  epiglottis  much  eroded. 

Superficial  ulcer  gives  only  slight  symptoms,  pain  being  often  wholly 
absent.  In  contrast  with  the  negative  signs  of  superficial  ulcers  deep 
ulceration  is  often  exceedingly  painful,  especially  when  the  perichon- 
drium is  involved.  Dyspnea  may  be  present,  especially  if  a  gummy 
tumor  obstruct  the  air-passage.  After  it  has  broken  down  in  ulcera- 
tion this  symptom  is  relieved. 

Diagnosis  presents  few  difficulties,  particularly  if  the  existence  of 
the  disease  in  the  system  is  known.  Mucous  patches  show  a  grayish 
area  slightly  raised  above  the  general  level  of  the  membrane.  The 
bright-yellow  pus  of  the  superficial  ulcer  is  characteristic.  A  gummy 
tumor  is  smooth  and  rounded. 

The  deep  ulcer  has  a  sharply-defined  edge,  is  crater-like,  and  has  a 
dark-red  areola,  much  secretion,  and  necrosed  tissue. 

It  must  be  differentiated  from  tubercular  disease  and  malignant 
disease. 

In  tuberculosis  the  ulcer  is  irregular,  of  a  grayish  color  like  the 
surrounding  membrane,  has  little  secretion,  and  may  be  accompanied 
by  pyrexia.  Microscopical  examination  will  show  also  the  tubercle 
bacillus.  Malignant  disease  is  irregular,  nodular,  and  unilateral. 
Microscopic  examination  of  a  bit  of  the  tissue  will  show  the  cell- 
arrangements  peculiar  either  to  sarcoma  or  carcinoma. 

Prognosis. — Taken  in  the  earliest  stages,  laryngeal  syphilis  yields 
readily  to  constitutional  treatment,  combined  with  such  local  treatment 
as  would  be  given  for  the  comfort  of  the  patient  in  ordinaiy  catarrhal 
laryngitis. 

Treatment. — For  all  manifestations  of  syphilitic  disease  before  the 
appearance  of  the  superficial  ulcer  constitutional  treatment  alone  usually 
suffices.  With  the  appearance  of  this  ulcer  cleansing  and  antiseptic 
remedies  should  be  topically  employed.  The  treatment  of  a  gummy 
tumor  is  constitutional  only,  its  absorption  before  ulceration  begins 
being  the  thing  to  be  desired.  Deep  ulceration  must  be  treated  locally 
by  cleansing,  astringent,  and  antiseptic  solutions,  and  iodid  of  potas- 
sium is  to  be  pushed  internally. 

Resulting  cicatricial  stenosis  must  be  treated,  as  that  condition  is 
elsewhere,  by  dilatation  or  division. 

Tumors  of  the  I/arynx. — Morbid  growths  in  the  larynx  are 
common,  and  of  these  the  greater  number  are  benign.  They  may 
appear  either  externally  or  internally,  but  more  frequently  they  are 
internal,  occasionally  both.  The  symptoms  are  such  as  naturally  give 
great  alarm  to  the  patient  and  his  friends,  but  danger  to  life  is  rela- 
tively slight. 

Benign  Tumors. — All  or  nearly  all  varieties  of  benign  tumors  have 
been  found  in  the  lar>'nx,  and,  in  the  order  of  frequency,  are  papilloma, 
fibroma,  osteoma,  myxoma,  adenoma,  lipoma,  angeioma,  enchondroma, 
and  those  of  mixed  character.  Some  of  them  undergo  degeneration, 
fatty,  colloid,  and  amyloid. 

Papillomata  outnumber  all  other  kinds  of  neoplasms  put  together. 


624  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

and,  while  most  morbid  growths  are  single,  these  are  occasionally 
multiple. 

Men  suffer  more  frequently  than  women  from  this  disease,  and 
during  the  more  active  period  of  life,  from  thirty  to  fifty.  It  appears  so 
early  in  infancy  that  it  may  be  assumed  to  be  congenital,  nor  is  ad- 
vanced old  age  free  from  it. 

The  favorite  sites  of  neoplastic  growths  are  the  anterior  parts  of  the 
larynx,  notably  the  vocal  cords,  though  they  appear  anywhere  on  the 
laryngeal  surface. 

The  size  varies  from  that  of  a  millet-seed  to  a  growth  large  enough 
to  protrude  from  the  larynx  and  threaten  life  from  asphyxia. 

Etiology. — The  cause  is  obscure,  and  it  is  rare  indeed  that  a  definite 
one  can  be  found  for  any  particular  case. 

Acute  and  chronic  laryngitis,  especially  under  exposure  to  cold  and 
to  irritating  vapors,  over-use  of  the  voice,  the  deuteropathic  laryngitis 
of  acute  and  constitutional  diseases,  and  traumatism  have  all  been  as- 
signed as  causes  of  benign  tumors  in  the  larynx.  But  such  diseases  do 
not  produce  tumors  in  the  majority  of  cases,  and,  on  the  other  hand, 
tumors  develop  when  no  morbid  process  can  be  assigned,  and  are  sur- 
rounded by  perfectly  healthy  tissue,  just  as  a  "wart"  develops  on  the 
cutaneous  surface  of  the  hand. 

Symptoms. — All  varieties  of  benign  tumors  produce  the  same  symp- 
toms, according  to  size  and  location.  Since  most  of  these  tumors  are 
either  upon  the  vocal  cords  or  near  enough  to  them  to  modify  their 
function,  phonation  is  either  altered  or  lost.  Before  or  in  place  of 
complete  aphonia  there  may  be  either  a  weak  or  a  hoarse  voice,  and 
the  earliest  indication  of  the  presence  of  a  laryngeal  tumor  may  be 
a  certain,  almost  indefinable,  alteration  in  the  quality  and  tone  of  the 
voice,  such  alterations  being  more  pronounced  or  being  replaced  by 
aphonia  as  the  disease  progresses. 

If  there  are  growths  on  the  two  sides,  so  that  the  chink  of  the  glot- 
tis is  divided,  double  voice  or  diphthonia  may  result. 

Position  rather  than  size  determines  the  alteration  in  the  voice.  A 
small  tumor  seated  on  the  weak  bands  may  impair  their  function 
greatly,  w^hen  one  many  times  the  size  situated  at  some  distance  will 
affect  the  voice  little  or  none  at  all. 

Respiration,  especially  during  inspiration,  may  be  interfered  with, 
and  dyspnea  may  become  pronounced  with  the  enlargement  of  the 
growth. 

Dysphagia  is  not  common  unless  the  morbid  growth  occupies  the 
posterior  part  of  the  larynx.  Cough  is  seldom  present,  as  nerves  are 
rarely  injured,  and  pain  is  uncommon  for  the  same  reason. 

Hemorrhage  is  either  absent  or  slight.  The  growth  itself  may  not 
be  felt,  and  its  presence  may  be  unnoticed  except  for  interference  with 
phonation,  or  it  may  give  a  feeling  of  discomfort  and  uneasiness. 

Diagnosis  is  made  by  the  laryngoscope,  and  the  practitioner  needs 
to  be  thoroughly  acquainted  wdth  the  external  and  histological  cha- 
racters of  the  different  varieties  of  tumor,  as  well  as  the  probable  site, 
size,  and  mobility.  In  children,  the  use  of  the  laryngoscope  being 
sometimes  non-practicable,  the  tactus  erziditus  alone  must  give  the 
desired  information.     Even  when  the  laryngoscope  is   used,  a  snare  or 


INJURIES  AND  DISEASES   OF  THE   RESPIRATORY  SYSTEM.  625 

probe  may  be  needed  to  bring  a  growth  into  full  view.  When  possible 
a  portion  may  be  removed  for  microscopical  examination,  but  this  is 
not  always  desirable. 

Papilloniata  may  be  single,  but  are  often  multiple,  either  sessile 
or  pedunculated,  and  usually  found  at  the  anterior  part  of  the  vocal 
cords.  The  surface  is  wart-like,  and  the  interior  on  section  shows  the 
same  formation  in  its  central  papilla  covered  with  multiplied  epithelial 
layers.  They  vary  in  color,  through  shades  of  pink,  from  white  to  red. 
Their  appearance  when  they  are  multiple  has  been  compared  to  that  of 
mulberries.  They  are  common  in  childhood  and  adolescence — a  diag- 
nostic point  between  them  and  epitheliomata  which  occur  in  middle  life. 

Fibromata,  situated  most  commonly  also  on  the  vocal  cords,  are 
single,  smooth,  hard,  rounded,  pedunculated,  and  have  a  surrounding 
areola. 

Cystomata  are  caused  by  the  retention  of  a  secretion  in  a  mucous 
gland  from  an  obstructed  duct.  As  it  fills  it  projects  above  the  surface 
and  may  attain  the  size  of  a  small  marble.  It  occurs  most  frequently 
on  the  epiglottis,  is  round,  smooth,  semi-transparent,  movable,  com- 
pressible, and  pink  in  color. 

Myxoinata  are  probably  due  to  the  myxomatous  degeneration  of  the 
mucous  membranes  or  of  other  tumors,  and  are  found  most  frequently 
upon  the  vocal  cords.  In  situation  and  external  character  they  so 
much  resemble  papillomata  as  to  suggest  the  idea  that  they  are  a 
degeneration  of  that  common  form  of  laryngeal  tumor. 

Angeiomata  are  rare,  and  are  usually  seated  upon  the  vocal  cords, 
but  may  be  found  anywhere.  They  vary  in  size  from  that  of  a  pea  to 
a  hazelnut,  and  are  of  a  deep-red  color. 

Adenomata  are  so  rare  that  their  occurrence  is  denied  by  some 
specialists  in  throat  diseases,  but  there  can  be  no  doubt  of  their  occa- 
sional existence. 

Lipomata  are  supposed  to  be  external  neoplasms  as  a  rule,  though 
Bruns  reports  one  of  intra-laryngeal  origin. 

EiicluvidroDiata  are  more  commonly  seen  upon  the  posterior  por- 
tions of  the  larynx,  selecting  as  favorite  sites  the  cricoid,  the  thyroid, 
and  the  epiglottis  in  the  order  named.  These  tumors  are  always  hard, 
large,  and  sessile,  projecting  inward.  Their  contour  is  irregular,  and  when 
the  mucous  membrane  is  eroded  they  are  seen  to  be  hyaline  in  struc- 
ture. They  may  be  very  small,  or  so  large  as  to  fill  the  laryngeal 
cavity,  giving  rise  to  extreme  dyspnea.  Few  tumors  are  composed  of 
one  histological  substance,  but,  as  in  other  parts  of  the  body,  are  of 
mixed  type. 

Prolapse  of  the  ventricle  may  be  mistaken  for  neoplastic  growth. 
It  can  be  diagnosed  by  noting  the  absence  of  the  ventricle  and  by 
replacing    the  membrane  temporarily  with  an  instrument. 

Prognosis. — Per  sc,  tumors  of  this  sort  do  not  menace  life.  By 
occlusion,  if  they  are  allowed  to  attain  a  large  size,  they  may  cause 
suffocation  ;  but  the  increase  in  size  is  always  slow,  and  if  there  are  any 
reasons  why  the  growth  cannot  be  removed,  the  operation  of  trache- 
otomy can  be  performed.  As  a  rule,  also,  prognosis  as  to  recovery  of 
voice  is  good  if  this  has  been  impaired  or  lost,  though  in  rare  cases  it 
may  never  be  restored. 

40 


626  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

When  a  growth  has  been  removed  by  the  external  operation, 
cicatrization  of  the  thyroid  cartilage  may  so  distort  the  parts  that  the 
normal  voice  is  lost. 

Occasionally  benign  growths  undergo  transformation  into  malignant 
tumors,  especially  when  they  are  subjected  to  some  constant  irritation 
or  when  repeated  clumsy  attempts  at  operation  are  made,  but  the 
proportion  of  such  degenerative  alterations  is  exceedingly  small. 

Sometimes  spontaneous  expulsion,  or  still  more  rarely  spontaneous 
absorption,  takes  place. 

Treatment. — Treatment  is  wholly  surgical,  and  two  methods  of 
removal  are  recognized,  the  intra-laryngeal  and  the  extra-laryngeal. 
With  the  laryngoscope  and  the  variety  of  laryngeal  instruments  now  at 
the  surgeon's  command  it  is  rare  indeed  that  intra-laryngeal  operation 
will  not  be  abundantly  successful.  Not  all  intra-laryngeal  growths 
demand  immediate  operative  interference.  If  the  symptoms  and  the 
inconvenience  are  slight  and  the  growth  does  not  enlarge,  it  is  optional 
whether  the  operation  is  performed  or  not.  Such  a  growth  may  remain 
stationary  for  an  indefinite  period,  and  then  begin  to  enlarge,  and  this 
indicates  prompt  removal. 

Operation  through  the  natural  passages  is  by  cauterization,  incision, 
abscission,  excision,  crushing,  ecrasement,  and  avulsion. 

Cauterization  is  effected  by  chemical  or  electrical  agency.  When  the 
former  is  selected,  as  it  may  be  in  the  case  of  small,  easily  accessible  papil- 
lomata,  a  variety  of  caustics  has  each  its  advocates,  as  nitric  acid,  nitrate 
of  silver,  zinc  chlorid,  caustic  potash,  mercuric  nitrate,  London  paste, 
Vienna  paste,  or  chromic  acid.  A  tiny  crystal  of  chromic  acid  is  fused 
on  the  end  of  a  curved  laryngeal  probe  and  applied  to  the  neoplasm. 
A  concentrated  solution  may  be  applied  by  means  of  a  bit  of  sponge 
or  cotton  held  firmly  in  catch-forceps.  The  greatest  care  must  be  used 
in  such  operations  not  to  drop  foreign  substances  into  the  respiratory 
passages,  and  also  to  accustom  both  patient  and  surgeon  to  the  neces- 
sarily delicate  manipulations.  Preliminary  attempts  may  be  made  with 
the  simple  instruments  not  carrying  any  caustic  whatever,  for  in  the 
actual  operation  the  greatest  care  must  be  exercised  to  touch  no  por- 
tion of  the  laryngeal  surface  except  the  papilloma. 

Similar  precautionary  measures  may  be  taken  when  the  galvano- 
cautery  is  used.  Various  cautery  points  are  made  for  laryngeal  treat- 
ment, and  may  require  wrapping  down  almost  to  the  point  to  protect 
all  tissue  but  that  under  operation,  for  traumatic  laryngitis  or  edema 
of  the  larynx  may  follow  clumsy  manipulations.  The  point  must  be 
carefully  adjusted  before  the  current  is  turned  on,  and  the  current 
should  be  turned  off  before  the  instrument  is  removed.  Cauterization 
by  the  galvano-cautery  is  really  one  of  the  least  desirable  of  all  methods 
of  treatment  unless  in  the  hands  of  a  most  skilful  operator. 

Incision  is  employed  for  cysts  only,  and  a  curved  knife  is  used. 

Abscission  and  excision,  practically  one  and  the  same  operation  on 
growths  of  slightly  different  shape,  are  done  by  knives  of  various  curve 
properly  protected  nearly  to  the  end,  by  scissors,  or  by  the  guillotine. 

Crushing  is  accomplished  by  forceps,  and  is  not  primarily  a  removal, 
but  a  destruction  of  the  vitality  of  the  neoplasm,  with  the  expectation 
that  it  will  eventually  slough. 


INJURIES  AND  DISEASES   OF  THE   RESPIRATORY  SYSTEM.    627 

Ecrasement  is  detachment  by  means  of  the  snare,  and  is  applicable 
only  to  growths  of  small  size,  but  has  the  advantage  of  only  slight 
hemorrhage  if  done  slowly. 

Evulsion  is  the  method  adapted  to  the  greater  number  of  new 


Fig.  264. — Storck's  forceps  :  A,  wire  ecraseur  ;  B  and  C,  guillotines  ;  D,  E,  and  F,  forceps  ; 
G,  guillotine,  half  closed  ;  H,  the  same,  open. 

growths.  The  growth  is  grasped  by  forceps  and  torn  away  either 
en  masse  or  piecemeal.  Soft  growths,  either  pedunculated  or  sessile, 
come  away  very  readily,  but  those  of  harder  consistency,  as  fibromata, 
often  are  removable  with  great  difficulty.     If  hemorrhage  is  so  great 


Fig.  265. — Gottstein's  forceps. 


as  to  obscure  the  field  in  the  case  of  a  growth  removed  in  fragments, 
several  sittings  may  be  necessary.  A  finger  in  the  lar>'nx  sometimes 
easily  detaches  foreign  growths. 

What  form  of  instruments  to  use  is  a  question  of  some  nicety,  and 


628 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


different  surgeons  have  devised  instruments  adapted  to  their  own  par- 
ticular manner  of  operating.  Mackenzie  of  London  perfected  a  forceps 
bent  at  right  angles  and  intended  to  operate  in  the  entire  circumference 
of  the  larynx.  He  has  also  invented  tube-forceps,  less  generally  used 
than  the  other,  and  of  a  less  wide  range  of  usefulness. 

Storck's  instrument  (Fig.  264)  is  bent  to  the  quadrant  of  a  circle, 
and  may  be  adjusted  to  a  universal  handle. 

Gottstein  has  an  instrument  (Fig.  265)  with  one  curve  nearly  at 
right  angles  in  the  distal  end,  and  another  at  the  junction  of  the 
handle  and  the  instrument  proper,  but  most  operators  use  it  awkwardly. 

Many  find  Shrotter's  instruments  (Fig.  266)  very  useful  on  account 


Fig.  266. — Schrotter's  laryngeal  lancet  and  forceps. 

of  the  handles  being  bent  horizontally  out  of  the  operator's  line  of 
vision. 

The  extra-laryngcal  operation  is  to  be  performed  when  the  growth 
is  so  large  or  so  situated  as  to  make  thorough  eradication  through  the 
mouth  either  doubtful  or  impossible. 

A  preliminary  tracheotomy  may  be  done  and  the  method  through 
the  mouth  again  attempted,  or  the  tracheotomy  may  be  performed 
only  with  a  view  to  removal.  Where  entrance  shall  be  made  must 
depend  upon  the  individual  case.  It  may  be  through  the  median  line 
of  the  thyroid,  or  through  the  crico-thyroid  ligament,  or  through  both 
cricoid  and  thyroid,  or  the  trachea  may  be  opened,  or  the  section  made 
partly  in  the  trachea  and  partly  in  the  larynx.  Section  may  be  between 
the  hyoid  bone  and  the  larynx,  but  this  reaches  little  surface  that  is  not 
equally  accessible  by  the  mouth  ;  a  lateral  section  has  been  proposed. 

The  cricoid,  having  a  comparatively  small  blood-supply,  is  prone  to 
necrosis,  and,  as  has  been  said,  cicatrization  after  operation  upon  the 
thyroid  cartilage  is  apt  to  distort  the  vocal  cords  and  impair  the  voice. 
All  considerations  must  be  duly  weighed  before  commencing  the  ope- 
ration. 

After  having  entered  upon  so  important  an  operation  the  surgeon 
will  see  to  it  that  extirpation  is  so  radical  that  repullulation  is  inevitably 
forestalled.  Thorough  cauterization  of  the  parts  upon  which  ablation 
has  been  practised  will  secure  this.  If  hemorrhage  after  thyrotomy  is 
large,  the  operation  may  have  to  be  done  in  two  stages,  and  it  is  best 
to  leave  in  a  tracheotomy-tube  if  possible,  as  resolution  is  more  rapid 
when  perfect  rest  to  the  parts  is  thus  secured. 


INJURIES  AND   DISEASES   OF   THE   RESPIRATORY  SYSTEM.   629 

Cocain  should  be  used  before  commencing  internal  operation  upon 
the  throat.  The  case  should  be  treated  immediately  with  caustics  if 
there  is  any  appearance  of  remaining  fragments  or  if  recurrence 
threatens. 

It  is  only  practice  upon  the  cadaver  that  will  give  the  requisite 
rapidity  and  delicacy  of  manipulation. 

Malignant  Ttimors. — Tumors  of  malignant  character  are  either 
sarcomata  or  carcinomata,  the  proportion  of  the  latter  to  the  former 
being  612  to    i   (Bosworth). 

1.  Sarcoma. — All  or  nearly  all  varieties  of  sarcoma  have  been 
reported  as  found  in  the  larynx.  Sarcomata  are  not  excessively  large, 
about  the  size  of  a  walnut  being  the  limit.  They  extend  by  involving 
adjacent  tissue,  and  not  by  the  lymphatics.  The  disease  occurs  most 
frequently  in  adult  males  between  the  ages  of  twenty-five  and  sixty, 
with  the  majority  of  cases  in  old  age.  The  disease  is  usually  primary, 
with  no  evidence  of  hereditary  predisposition,  though  a  very  few  cases 
have  been  reported  as  secondary. 

No  cause  is  known,  but  possibly  persistent  laryngitis  may  have  some- 
thing to  do  with  it,  though  an  otherwise  healthy  larynx  may  be  the 
seat  of  sarcoma. 

Symptoms  in  the  early  stages  may  be  nearly  negative,  or  at  least 
may  not  differ  from  those  of  the  non-malignant  tumor.  Pain  may  be 
more  marked,  but  in  some  cases  is  wholly  absent.  As  the  disease 
advances  cough  may  assert  itself,  and  the  sputa  may  alter  in  character, 
containing  some  blood  and  eroded  fragments. 

Diagnosis. — Diagnosis  is  made  by  the  microscope.  Yet  to  the 
practised  eye  certain  distinguishing  characteristics  will  declare  the 
malignancy  of  the  growth,  for  it  does  not  exactly  resemble  any  of  the 
benign  tumors.  Occasionally  it  resembles  a  papilloma,  but  it  is  situated 
more  posteriorly.  There  is  an  abnormal-looking  mucous  membrane 
immediately  surrounding  the  growth,  either  pale  or  too  vascular,  and 
sometimes  there  is  superficial  ulceration.  There  is  a  thick  deposit  of 
muco-pus  upon  the  irregularly-shaped  mass. 

Sarcoma  is  distinguished  from  carcinoma  by  the  fact  that  the 
lymphatic  glands  are  not  involved. 

Prog-}iosis. — Let  alone,  the  disease  is  fatal,  and  may  be  quickly  so, 
for  at  times,  especially  in  the  later  stages,  the  tumor  grows  very  rapidly, 
filling  the  larynx,  death  resulting  from  suffocation.  If  the  growth  is 
wholly  removed,  the  prognosis  becomes  favorable. 

Treatment. — Extirpation  is  the  only  safe  procedure,  and  here  radical 
treatment  is  surgical.  In  so  grave  a  disorder,  where  the  removal  of 
every  particle  of  the  growth  is  essential  and  where  repeated  manipulations 
result  only  in  evil,  the  operation  through  the  mouth  does  not  sufficiently 
promise  certain  success.  Thyrotomy  must  be  the  rule  here.  Some- 
times there  must  be  resection  of  a  portion  of  the  larynx,  or  even 
laryngectomy.  If  the  disease  is  confined  to  the  epiglottis,  that  may  be 
removed  entire. 

2.  Carcinoma. — Of  all  the  cases  of  cancer,  only  a  very  small  per- 
centage are  located  in  the  larynx.  Here  it  is  usually  primary,  but  has 
been  known  to  be  secondary  by  extension  from  neighboring  organs.  It 
is  not  circumscribed,  but  spreads   rapidly  into  contiguous  tissues,  and 


630  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

hence,  though  generally  unilateral  to  begin  with,  it  becomes  bilateral 
by  extension. 

Ifitriiisic  cnrcijioina  hovers  about  the  vocal  bands,  while  the  extrinsic 
variety  more  frequently  selects  the  epiglottis  as  its  site.  Lymphatic 
glands  are  not  always  involved,  especially  in  intrinsic  carcinoma,  the 
extrinsic  variety  being  more  apt  to  extend  to  the  lymphatics. 

It  occurs  at  all  ages,  but  is  most  frequent  in  the  last  part  of  the 
so-called  middle  life  and  in  old  age  from  fifty  to  seventy,  and  occurs  in 
males  far  more  frequently  than  in  females. 

The  cause  is  obscure,  but  acute,  and  especially  chronic,  laryngitis, 
traumatism,  the  contraction  of  cicatrices,  over-use  of  the  voice,  the 
irritation  of  benign  growths,  and  especially  clumsy  attempts  at  their 
removal,  have  all  been  assigned  as  causes. 

Symptoms. — The  symptoms  arc  essentially  the  same  as  of  malign 
growths  in  the  early  stages. 

The  glands  are  early  involved.  There  is  generally  some  ulceration, 
a  more  abundant  secretion  than  normal,  and  thus  the  breath  becomes 
fetid  and  offensive  and  the  sputa  charged  with  abnormal  constituents 
and  tinged  with  blood.  Although  it  is  rare,  the  ulceration  may  eat 
through  small  arteries  and  hemorrhage  ensue. 

Pain  is  not  constant,  but  is  usually  more  marked  than  with 
benign  tumors  or  sarcoma,  and  a  peculiar  feature  is  that  it  radiates 
up  behind  the  ears  and  over  the  neck,  particularly  in  extrinsic  car- 
cinoma. 

Salivation  may  be  excessive.  Cough  in  the  ulcerative  stage  is 
usually  present. 

Sometimes  dyspnea  is  so  extreme  as  to  threaten  suffocation.  After 
a  time  these  extreme  symptoms  remit,  the  reason  being  the  removal  of 
tissue  by  the  ulcerative  process. 

Diagnosis. — The  true  character  of  carcinoma  of  the  larynx  may  be 
overlooked  at  first,  from  the  fact  that  it  is  deep  within  the  tissues 
before  its  presence  is  known.  Careful  study  of  the  subjective  symp- 
toms and  superficial  appearance  of  the  tumor,  particularly  in  the 
ulcerative  stage,  the  fetid  breath,  and  the  pain  running  up  toward  the 
ears,  will  be  enough  to  suggest  cancer. 

The  final  diagnosis  is  by  the  microscope,  and  fragments  should  be 
removed  from  a  suspected  tumor  for  that  purpose.  Its  nodular,  ragged, 
irregular,  and  greater  extent  serves  to  distinguish  it  from  sarcoma. 
Cachexia  is  characteristic  also,  but  less  so  than  with  cancer  in  other 
parts  of  the  body,  and  it  does  not  appear  early  as  a  rule.  By  micro- 
scopic examination  it  can  be  differentiated  from  tuberculosis,  and  by 
specific  treatment  from  syphilis. 

Prognosis. — It  is  a  fatal  disease.  Removal  may  lengthen  life,  but 
will  not  save  it. 

Treatment. — Since  the  patient  becomes,  from  the  fetor,  very  offensive 
to  himself  and  his  attendants,  it  is  best  to  use  sprays  of  antiseptic  and 
deodorizing  material,  as  carbolic  solutions,  peroxid  of  hydrogen,  per- 
manganate of  potash,  etc. 

Pain  is  to  be  relieved  by  the  use  of  morphin. 

If  dyspnea  is  extreme,  tracheotomy  is  to  be  performed. 

Whether  actual   attempts   at    surgical    extirpation    shall    be    made 


INJURIES  AND  DISEASES   OF  THE   RESPIRATORY  SYSTEM.   63 1 

depends  upon  the  strength  and  wish  of  the  patient  and  the  position 
and  extent  of  the  growth. 

If  it  is  external,  operation  is  useless.  If  it  is  intrinsic  and  unilateral, 
a  half  section  of  the  larynx  may  eradicate  it,  or  if  of  limited  extent  and 
bilateral,  laryngectomy  may  be  justifiable. 

Neuroses   of  the   Larynx. 

Neuroses  of  the  larynx  are  either  sensory,  paralytic,  or  spasmodic. 

Sensory  neuroses,  in  comparison  with  the  paralytic  disorders  of 
the  larynx,  seem  relatively  unimportant,  and  are  usually  transitory  or 
mere  concomitants  of  disease  of  the  larynx. 

During  certain  diseases,  notably  tuberculosis  and  carcinoma,  there 
is  hyperesthesia  of  the  mucous  surface  of  the  larynx;  this  occurs  more 
transiently  and  to  a  lesser  degree  in  acute  than  in  chronic  laryngitis. 

After  certain  diseases,  as  diphtheria,  and  sometimes  after  syphilis, 
there  is  anesthesia  of  the  mucous  surface.  This  is  a  concomitant  also 
of  some  purely  nervous  diseases  involving  the  superior  laryngeal  nerve. 

In  neurotic  individuals  paresthesia  is  not  uncommon.  It  may  be 
due  to  some  disease  or  it  may  be  purely  or  nearly  imaginary.  Exam- 
ination often  reveals  unsuspected  disease,  and  sometimes  no  cause  can 
be  found. 

Neuralgia  of  the  larynx,  though  very  rare,  may  be  a  part  of  neur- 
asthenia or  the  result  of  a  generally  anemic  or  depleted  condition,  and 
is  then,  as  a  rule,  accompanied  by  neuralgia  in  other  parts  of  the  body. 
It  may  also  occur  independently  of  the  disease  elsewhere.  It  is  usually 
most  painful.  Sensory  neuroses,  except  as  symptoms  of  surgical  dis- 
eases of  the  larynx,  possess  little  interest  for  the  surgeon,  and  fall  more 
properly  within  the  domain  of  the  medical  practitioner. 

Paralysis. — Functional  paralysis  occurs  chiefly  in  hysterical  sub- 
jects, and  requires  the  same  treatment  which  that  disorder  receives 
whatever  its  manifestations. 

By  paralysis  is  meant  an  organic  affection  of  the  nerve  supplying 
the  larynx.  It  may  be  due  to  a  lesion  in  the  nerve  itself  anywhere  in 
its  course  or  to  mechanical  interference  with  its  function,  as  when  there 
is  pressure  upon  it  from  tumors  or  infiltrations.  Ankylosis  of  an  artic- 
ulation may  put  an  end  to  the  function  of  the  part,  but  is  not  a  true 
paralysis,  since  the  nerve  is  wholly  unaffected.  Paralysis  may  be  partial 
or  complete. 

Paralysis  of  the  Superior  Laryngeal  Nerve. — Sensation  for  the 
mucous  membrane  of  the  entire  larynx  is  provided  by  this  nerve,  and 
it  supplies  motor  fibers  also  to  the  crico-thyroid  muscle  and  partly  to 
the  ar>^tenoids.  Hence  a  complete  paralysis  of  this  nerve  would  pro- 
duce anesthesia  of  the  lar>mgeal  mucous  membrane  and  motor  paral- 
ysis of  the  crico-thyroid  and  arytenoideus  muscle.  Tension  of  the 
cords  would  be  interfered  with,  and  there  would  be  lack  of  approxima- 
tion of  the  arytenoid  cartilages.  This  affection  may  be  unilateral  or 
bilateral,  the  former  condition  being  due  more  frequently  to  local  dis- 
ease or  injury,  the  latter  to  cerebral  disease  or  extensive  local  injury. 

The  commonest  cause  of  paralysis  of  this  nerv^e  is  diphtheria.  It 
is  then  accompanied   by  complete  anesthesia,  and  by  anesthesia  and 


632  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

paralysis  of  neighboring  parts,  as  in  the  pharynx  when  the  muscles 
of  deglutition  are  involved.  Other  exhausting  diseases,  as  typhoid 
fever,  have  been  known  to  produce  this  condition. 

Diagnosis  is  based  upon  the  history  of  the  case,  with  a  study  of  the 
action  of  the  laryngeal  muscles  by  means  of  the  laryngoscope,  together 
with  the  fact  that  anesthesia  of  the  mucous  membrane  is  also  present. 

If  paralysis  is  bilateral,  only  the  vocal  processes  touch  during 
phonation,  making  an  elliptical  opening  in  front  and  a  triangular  pos- 
teriorly. If  it  is  unilateral,  the  laryngoscopic  image  is  less  distinctive, 
for  it  then  resembles  merely  a  relaxed  condition  of  the  cord  (Bosworth). 

Prognosis  is  good,  though  complete  recovery  is  slow. 

Treatment. — The  diet  must  be  nutritious.  Electricity,  the  faradic 
form,  is  of  good  service.  Strychnin  is  the  best  drug  for  this  condition, 
but  general  tonics  are  usually  needed.  If  the  origin  of  the  disease  is 
syphilitic,  specific  treatment  is  necessary.  If  it  is  of  central  origin, 
nothing  can  be  done  unless  the  central  lesion  is  due  to  syphilis. 

Recurrent  Laryngeal  Paralysis. — This  nerve  supplies  with  motion 
all  muscles  of  the  larynx  except  the  crico-thyroid,  and  hence  when  it 
is  paralyzed  there  is  complete  absence  of  motion  in  all  parts  of  the 
larynx,  for  the  crico-thyroid  muscles  act  to  no  effect  alone,  if  indeed 
they  act  at  all.  Long-continued  paralysis  of  these  nerves  leads  to 
degeneration  of  the  nerve  itself,  and  consequently  to  degeneration  and 
atrophy  of  the  muscles  which  they  innervate,  and  not  infrequently  to 
ankylosis  of  the  cartilages  of  the  larynx  from  long-continued  disuse. 

Etiology. — The  commonest  cause  of  paralysis  of  this  nerve  is  pres- 
sure upon  it  at  some  part  of  its  course.  The  course  of  the  right  and 
left  recurrent  laryngeal  nerves  respectively  is  not  the  same  on  both 
sides  of  the  body,  it  being  on  the  left  side,  as  it  winds  around  the  arch 
of  the  aorta,  more  exposed  to  pressure  from  aneurysmal  tumor  of 
that  vessel.  Statistics,  however,  do  not  seem  to  show  that  aneurysm 
is  accountable  for  the  relatively  larger  number  of  paralyses  of  the  left 
recurrent  laryngeal  nerve,  but  to  such  a  cause  must  be  added  also  its 
greater  exposure  on  that  side. 

Lesions  existing  anywhere  in  the  course  of  the  nerve  will  cause 
paralysis. 

Any  disease  of  the  brain  where  this  nerve  in  its  beginning  is  involved 
or  pressed  upon  will  cause  paralysis.  During  its  course  it  may  be  pressed 
upon  by  aneurysm,  enlarged  lymphatic  glands,  mediastinal  tumors,  pleu- 
ritic or  cardiac  effusion,  cancer  of  the  esophagus,  or  enlargement  of  the 
thyroid  gland.  Causes  affecting  the  peripheral  terminations  are  less 
frequent  probably  than  any  other.  They  are  inflammation  of  the  laryn- 
geal mucous  membrane,  usually  involving  that  of  the  pharynx  as  well, 
and  inflammation  of  the  muscles  of  the  larynx,  especially  with  great 
effusion  into  their  substance.  Rheumatism  of  these  muscles  is  believed 
to  cause  it,  also  anemia,  syphilis,  poisoning  by  drugs,  blood-poisoning 
by  diphtheria,  typhoid  fever,  and  the  exanthemata. 

The  paralysis  due  to  pressure  on  the  recurrent  laryngeal  nerve 
of  one  side  sometimes  is  accompanied  by  paralysis  of  the  nerve  of 
the  other  side,  and  this  has  never  been  satisfactorily  explained.  The 
suggestion  has  been  made  that  the  irritation  of  the  one  affected  leads 
to  central  changes  felt  by  the  other. 


INJURIES  AND   DISEASES   OF   THE   RESPIRATORY  SYSTEM.    633 

Ziemssen  reports  a  case  where  there  was  bilateral  paralysis,  that  on 
the  left  side  being  due  to  aneurysm  of  the  aorta,  the  other  to  aneur>^sm 
of  the  subclavian  artery. 

Symptoms. — At  the  onset  of  the  affection  in  unilateral  paralysis  the 
voice  is  weak,  but  with  time  it  nearly  recovers  its  normal  strength. 

In  bilateral  paralysis  phonation  is  completely  lost,  and  there  is  rapid 
loss  of  air  through  the  glottis  when  the  attempt  to  speak  is  made. 
Dyspnea  is  common.  Laryngeal  paralysis  is  really  a  symptom,  as  a 
rule,  of  some  grave  disease,  and  the  concomitant  symptoms  of  that 
disease  are  present  as  well. 

Diagnosis. — Objective  symptoms  in  lar>nigeal  paralysis  will  suggest 
the  disorder,  especially  in  connection  with  the  history.  Diagnosis, 
however,  is  verified  by  the  laryngoscope. 

The  vocal  cords  occupy  the  cadaveric  position  of  Ziemssen  between 
extreme  abduction  and  adduction.  In  unilateral  paralysis  the  cord  on 
the  affected  side  is  in  the  cadaveric  position  ;  the  other  passes  the 
median  line  a  little,  as  if  to  compensate  as  much  as  possible  for 
the  disability  of  its  fellow.  The  arytenoid  cartilage  also  goes  a  little 
past  the  normal  position.  These  deviations  from  the  normal  give 
to  the  rima  glottidis  an  apparent  deflection  toward  the  paral)'zed 
side. 

In  many  cases  of  recurrent  larjmgeal  paralysis  the  cause  is  perfectly 
apparent,  for  the  paralysis,  as  has  been  said,  is  but  a  symptom  of  a 
grave  disorder.  On  the  other  hand,  the  laryngeal  paralysis  may  be  the 
first  indication  of  a  serious  systemic  affection,  and  it  then  becomes  the 
duty  of  the  surgeon  to  trace  backward,  as  it  were,  until  he  finds  the 
seat  of  the  obscure  disease — it  may  be  in  the  central  nervous  system, 
in  tumors  or  aneurysm  within  the  chest,  or  in  tumors  or  enlarged  glands 
in  the  cervical  region. 

Prognosis. — If  the  cause  is  some  acute  disease  or  even  poisonous 
drug,  the  outlook  is  more  encouraging  than  for  pressure  on  the  nerve- 
trunk,  and  least  of  all  is  it  hopeful  when  the  trouble  originates  in  the 
brain,  for  this  is  usually  incurable. 

Treatment. — Remove  the  cause  if  possible.  If  the  peripheral  nerves 
only  are  affected  because  of  some  local  inflammation,  local  measures 
are  indicated,  as  the  use  of  astringents. 

Electricity  may  be  of  use  if  the  trouble  lies  primarily  in  the  muscles 
or  if  it  can  be  made  to  assist  absorption  of  a  tumor,  as  is  sometimes  the 
case.  General  hygienic  and  therapeutic  measures  are  to  be  carried  out 
as  for  superior  laryngeal  paralysis. 

Paralysis  of  the  Abductors. — When  the  posterior  crico-arytenoids 
are  paralyzed,  the  vocal  cords  are  brought  into  approximation,  as  in 
phonation.  Much  theorizing  has  been  done  as  to  the  cause  of  this 
paralysis,  but,  since  it  is  a  frequent  accompaniment  of  diseases  having 
their  origin  in  brain  lesions,  particularly  locomotor  ataxia,  it  is  highly 
probable  that  many  cases  are  of  central  origin.  Still  others  may  be 
produced  by  pressure  on  the  nerv^e-trunk  or  by  peripheral  lesions.  In 
bilateral  paralysis  during  the  inspiratory  act  the  vocal  cords  are  drawn 
close  together,  symptoms  of  dyspnea  become  very  urgent,  and  the  vocal 
cords  cannot  be  drawn  far  apart  under  any  circumstances.  During 
expiration  the  cords  are  forced  up  in  a  vaulted  manner,  separating  as 


634  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

they  rise,  so  that  the  column  of  air  has  free  exit.  The  abductor  muscles 
from  protracted  non-use  may  undergo  degeneration  and  atrophy. 

Unilateral  paralj'sis  is  apt  to  be  due  to  pressure ;  disease  of  the 
bilateral  variety  is  likely  to  have  a  central  origin.  Local  irritation  or 
injury  has  been  known  to  produce  it,  but  such  a  cause  is  more  likely  to 
be  followed  by  bilateral  paralysis. 

Dyspnea  is  not  urgent  if  it  exists  at  all,  and  the  lar)'ngoscope 
reveals  pathological  conditions  on  one  side  only.  It  may  remain 
unilateral  indefinitely  or  may  merge  into  bilateral  paralysis.  Trache- 
otomy is  never  a  necessity  for  unilateral  paralysis  of  the  abductors. 

Symptoms. — The  one  distinctive  symptom  is  inspiratory  dyspnea, 
with  at  times  great  inspiratory  stridor,  not  particularly  noticeable  at 
first,  but  increasing  in  severity  and  frequency  of  the  attacks  as  time 
goes  on.  Other  symptoms  are  those  of  the  disease  that  produces  the 
paralysis,  and  whatever  concomitant  symptoms  it  may  produce  in  other 
nerves  or  in  other  parts  of  the  body. 

On  laryngoscopical  examination  the  cords  are  seen  to  approach 
each  other  very  closely  and  to  be  lifted  apart  during  expiration  ;  they 
assume  a  normal  position  during  phonation,  for  the  voice  is  not  affected, 
except  that  it  suffers  interruption  in  utterance  from  the  stridulous  in- 
spiration. 

Prognosis  depends  upon  the  cause.  It  is  good  if  the  cause  is  merely 
local,  not  bad  if  due  to  pressure  of  a  benign  tumor,  and  very  bad  if  due 
to  pressure  of  malignant  growth,  aneurysm,  or  to  central  nervous 
affections. 

Increasing  unrelieved  dyspnea  is  always  of  grave  import,  but  trache- 
otomy may  come  to  the  rescue  for  this  condition. 

Treatment. — Tracheotomy  is  to  be  performed  when  the  dyspnea 
demands  it.  Otherwise  treatment  is  the  same  as  for  paralysis  of  the 
superior  laryngeal  nerve. 

Paralysis  of  the  Adductors. — In  this  disease,  when  bilateral,  the 
lateral  crico-arytenoids  are  drawn  far  back  against  the  wall  of  the 
larynx,  leaving  the  rima  glottidis  as  wide  as  possible.  In  unilateral 
disease  one  muscle  retreats  to  the  laryngeal  wall.  It  is  probably  not 
of  central  origin,  but  generally  of  local  causation,  although  diphtheria, 
lead-poisoning,  and  occasionally  typhoid  fever  may  produce  it. 

Bilateral  adductor  paralysis  is  so  rare  as  to  raise  a  question  as  to 
whether  it  really  exists,  or  whether  the  so-called  cases  were  not  hys- 
terical semblances  of  such  a  condition. 

In  unilateral  paralysis  the  cord  on  the  unimpaired  side  passes  the 
median  line,  somewhat  toward  the  immovable  fellow  of  the  opposite 
side,  and  its  arytenoid  passes  in  front  of  the  other,  these  positions 
making  an  oblique  rima  glottidis. 

Aphonia  is  the  symptom.  Laryngoscopic  examination  makes  clear 
the  diagnosis. 

The  prognosis  is  excellent. 

Treatment. — Local  treatment  for  the  local  condition  and  absolute 
discontinuance  of  all  attempts  to  use  the  voice  are  absolute  require- 
ments. General  tonics  and  the  best  hygienic  living  are  indicated.  Elec- 
tricity, preferably  the  faradic  current,  and  strychnin  are  also  valuable. 

Aphonia  is  a  symptom    easily  counterfeited  by  dishonest  persons, 


INJURIES  AND   DISEASES   OF   THE    RESPIRATORY  SYSTEM.   635 

and  either  hysteria  or  dissimulation  may  call  it  to  their  aid.  The  dis- 
tinguishing characteristic  is  this,  that  whereas  paralysis  of  the  adductors 
is  rarely  or  never  bilateral,  hysterical  aphonia  is  always  so,  and  dis- 
simulation is  simply  silence  with  perfectly  normal  laryngeal  muscles. 
In  either  case  anesthesia  or  surprising  the  patient  when  he  is  "  off 
guard  "  will  clear  up  the  doubtful  features  of  the  case. 

Paralysis  of  the  Internal  Tensors. — No  form  of  laryngeal  paraly- 
sis is  more  common,  because  of  the  frequency  of  chronic  laryngitis  and 
straining  of  the  voice  from  over-use.  When  included  in  some  local 
inflammation  the  thyroid  muscle  fails  to  contract  as  it  should.  The 
voice,  though  still  audible,  loses  its  modulatory  power,  is  weak  and 
unable  to  make  the  higher  notes  heard,  and  is  hardly  under  the  control 
of  the  patient.  It  is  usually  unilateral,  giving  the  "  Indian-bow  "  image 
of  the  glottis  in  the  laryngoscope  during  phonation,  but  it  may  be 
bilateral  when  the  image  is  an  ellipse.  Paralysis  of  the  arytenoideus 
often  accompanies  tensor  paralysis,  and  then  in  the  laryngoscopic  image 
the  vocal  processes  are  approximated,  shortening  in  front  the  "  Indian 
bow  "  or  elliptical  opening  in  the  glottis  during  phonation,  and  show- 
ing posterior  to  the  vocal  process  a  half  ellipse,  its  point  toward  the 
front,  its  base  posteriorly. 

If  paralysis  of  the  arytenoideus  occur  alone,  the  vocal  cords  during 
phonation  are  properly  approximated  in  front  of  the  vocal  processes, 
leaving  behind  them  a  triangular  opening.  Complete  restoration  is  the 
rule  in  these  cases,  and  local  treatment  with  tonics,  strychnin,  and 
possibly  electricity  constitutes  efficient  treatment. 

Spasm  of  the  Glottis. — Certain  diseases,  as  croup  or  diphtheria, 
may  create  or  closely  simulate  this  condition,  but  here  is  considered 
only  that  form  of  laryngisuins  stridulus  which  is  simply  of  nervous 
origin.  It  may  be  due  to  spasmodic  contraction  of  the  muscles,  which 
coapt  the  vocal  bands,  the  ventricular  bands,  or  of  those  which  close 
the  glottis.  Both  adults  and  children  are  subject  to  it,  but  particularly 
infants  of  delicate  health — the  scrofulous,  anemic,  rickety,  those  who 
are  in  their  first  dentition,  who  are  suffering  from  gastro-intestinal  ail- 
ments, from  whooping-cough,  or  in  whom  enlarged  glands  press  upon 
the  laryngeal  nerves,  or  in  whom  the  meninges  are  irritated  by  caries 
of  cervical  vertebrae. 

In  adults  the  immediate  cause  is  a  reflex  nervous  excitability  from 
a  variety  of  causes,  as  food  or  drink  "  going  the  wrong  way  "  into  the 
larynx,  the  entrance  of  foreign  bodies  into  the  air-passages,  etc. 

Quite  frequently  there  is  some  existing  disease  of  the  larjnix  that 
favors  the  occurrence  of  such  accidents,  as  tuberculosis,  syphilis,  or 
tumors,  either  benign  or  malignant,  either  internal  or  external,  pressing 
upon  one  of  the  nerves.  Severe  affections  of  the  pharynx  and  esoph- 
agus, causing  painful  deglutition,  predispose  to  spasm  of  the  glottis, 
because  then  food  and  drink  are  apt  to  get  into  the  larynx. 

Some  diseases  of  central  origin,  as  epilepsy  and  locomotor  ataxia, 
afford  frequent  examples  of  it,  and  a  condition  of  generally  uneven 
nervous  poise  is  said  to  be  predisposed  toward  it. 

Symptoms. — The  symptom  of  distinctive  character  is  the  paroxysmal 
stridulous  inspiration  which  occurs  at  intervals  and  lasts  a  few  seconds. 
The  intervals  between  the  spasmodic  attacks  may  be  hours  or  days, 


636  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

but  if  the  system  is  in  a  condition  predisposing  to  the  occurrence  of 
spasm,  they  usually  increase  in  severity  and  frequency,  particularly  in 
the  case  of  children,  and  also  with  them  the  attack  usually  comes  on 
at  night.  With  adults  the  disease  is  rarely,  if  ever,  feital.  In  the  case 
of  children  eclampsia  and  death  often  follow  severe  attacks,  and  may 
occur  after  convalescence  has  apparently  become  established. 

Diagnosis. — In  the  case  of  children  croup  would  first  suggest  itself,  but 
the  absence  of  fever  and  cough  and  the  natural  tones  of  the  voice  would 
suffice  to  exclude  croup.  The  generally  ill-nourished  condition  of  the 
little  patient,  inflamed  gums,  the  whooping-cough  that  is  present,  or 
gastro-intestinal  troubles  will  afford  data  for  the  cause  of  laryngismus 
stridulus.  If  laryngoscopic  examination  is  attempted,  the  placing  of 
the  instrument  is  apt  to  excite  spasm,  and  then  the  contracted  muscles 
are  seen  in  the  case  of  adults,  and  may  even  be  provoked  to  establish 
the  diagnosis. 

Bilateral  paralysis  of  the  abductors  may  cause  spasm,  but  is  more 
chronic,  less  severe,  lasts  longer,  and  a  study  of  the  laryngoscopic 
image  will  show  total  absence  of  action  in  the  abduction,  the  glottis  is 
less  rigid,  and  there  is  a  marked  absence  of  the  convulsive  movements 
that  attend  spasm  of  the  glottis. 

Prognosis. — Because  of  its  reflex  origin  it  is  not  fatal  in  adults. 
When  it  seems  as  if  suffocation  were  imminent,  relaxation  allows  of 
inspiration,  probably  because  of  the  sedative  effects  of  carbonic  acid 
which  is  in  excess  in  the  system,  but  tracheotomy  may  be  desirable  to 
ensure  comfort.  In  children  the  prognosis  is  unfavorable,  the  degree 
of  danger  depending  upon  the  cause  and  severity  of  the  attack. 

Trcatnioit. — The  causative  disease  must  be  treated,  sedatives  given 
for  the  excessively  neurotic  condition,  and  the  general  health  brought 
to  the  highest  possible  point  by  tonics,  nutritious  diet,  exercise,  cold 
baths,  massage,  and  whatever  other  measures  may  be  possible. 

With  children  the  immediate  convulsion  demands  fresh  air,  ammonia 
to  the  nose,  hot  water  to  the  feet,  cold  to  the  head,  flagellation,  holding 
of  the  nose,  loosening  of  clothing,  examination  to  see  if  there  is  an 
impacted  glottis  and  perhaps  a  hasty  tracheotomy. 

If  the  spasms  tend  to  repeat  themselves,  preparations  should  be 
made  by  the  attendants  for  rapid  treatment.  In  addition  to  the  meas- 
ures mentioned,  morphin  may  be  used,  preferably  hypodermically, 
amyl  nitrite  may  be  kept  at  hand  for  instant  inhalation. 

During  the  interval  between  the  attacks  the  cause  should  be  re- 
moved as  rapidly  as  possible,  and  the  system  built  up  by  dietary  and 
hygienic  measures. 

V.   STRICTURE   AND   STENOSIS   OF   THE    LARYNX    AND   TRACHEA. 

Stenosis  of  the  larynx  and  of  the  trachea  are  so  frequently  asso- 
ciated clinically,  and  the  causes  producing  the  affection  in  the  one  are 
so  nearly  identical  with  the  causes  in  the  case  of  the  other,  that  it  is  not 
less  scientific  than  convenient  to  treat  of  the  two  together.  Either  or 
both  structures  may  be  the  seat  of  stenosis,  and  there  may  be  one  or 
more  points  of  constriction,  though  usually  in  such  a  case  the  multiple 
points  of  constriction  have  the  same   causes,  or  causes   operating  at 


INJURIES  AND  DISEASES   OF  THE  RESPIRATORY  SYSTEM   637 

widely  different  times  may  be  chargeable  with  the  clinical  condition. 
The  cause  of  stricture  may  be  wholly  external  to  the  organ  (compres- 
sion-stenosis) or  within  its  cavity,  or  it  may  be  in  the  walls  of  it  {occhi- 
sion-steiwsis). 

Compression-stenosis  may  be  caused  by  aneurysmal  tumors, 
enlarged  thyroids,  thymus,  or  lymphatic  glands,  cicatricial  tissue,  cervi- 
cal abscess,  a  foreign  body,  and  by  a  diseased  cervical  vertebra,  ster- 
num, or  clavicle.  In  this  kind  of  stricture  the  integrity  and  character 
of  the  walls  of  the  organ  are  unimpaired,  but  they  undergo  involution 
from  the  pressure. 

Occlusion-stenosis  is  caused  by  cicatricial  connective  tissue,  by 
warping  or  distention  of  the  tube  itself,  usually  from  congenital  mal- 
formations, by  tumors,  foreign  bodies,  edema,  inflammation  of  mucous 
and  submucous  tissue,  submucous  hemorrhage,  paralysis  of  dilator 
muscles  or  spasm  of  constricting  muscles  of  the  larynx,  by  adhesion 
of  the  vocal  bands,  ventricular  bands,  or  ar>^tenoid  cartilages,  or  by  the 
presence  of  false  membranes. 

Injuries,  especially  gunshot  wounds  and  cuts  inflicted  with  suicidal 
intent,  are  productive,  in  the  process  of  healing,  of  connective  tissue 
which  ultimately  contracts,  producing  stenosis. 

Stenosis  varies  between  extreme  limits.  It  may  be  a  scarcely 
appreciable  diminution  in  the  caliber  of  the  organ  or  a  complete  ob- 
literation of  it.  It  is  commonest  and  most  important  at  the  glottis,  for 
here  the  lumen  is  narrowed,  and  to  all  other  causes  operating  in  other 
parts  of  the  canal  is  added  the  contraction  of  the  laryngeal  process. 

Under  long-existing  pressure  degenerative  changes  may  take  place 
in  the  tracheal  walls.  The  cartilaginous  rings  may  atrophy  or  become 
wholly  absorbed,  so  that  perforation  occurs. 

According  to  the  cause  stricture  is  permanent  or  temporary. 

Symptoms. — Whatever  the  cause  and  wherever  the  lesion,  the  symp- 
toms are  practically  the  same.  The  chief  symptom  is  dyspnea  on  exer- 
tion. It  may  take  months  or  years  to  develop,  but  when  due  to  false 
membrane  it  may  reach  its  height  in  a  few  hours.  In  any  case,  if  un- 
relieved, the  stridor  increases  and  the  stenosis  threatens  suffocation. 
The  face  is  pale,  livid,  drawn,  and  anxious,  and  the  pulse  becomes 
weak  and  fluttering.  Sensations  of  tightness  and  discomfort  are  felt 
in  the  chest.  Cough  is  not  always  present,  but  when  it  is  it  is  hard 
and  metallic.  The  voice  weakens  as  the  disease  progresses,  though  in 
chronic  cases  it  may  not  be  observed  at  first.  In  acute  cases,  where 
false  membrane  is  present,  deglutition  may  be  difficult  or  impossible. 

Physical  examination  reveals  an  altered  respiratory  murmur.  It  is 
harsh  and  strident,  and  in  extreme  cases  may  be  heard  across  the  room, 
and  on  auscultation  seems  to  pervade  the  entire  chest.  When  the 
larynx  is  the  seat  of  the  constriction,  it  descends  during  inspiration — a 
symptom  wholly  absent  when  the  constriction  is  in  the  trachea. 

Diagnosis  depends  upon  the  symptoms,  the  history  of  the  case, 
and  laryngoscopic  examination.  It  must  not  be  overlooked  that  a 
slowly-developing  stenosis  is  a  far  different  thing,  so  far  as  prognosis 
and  treatment  are  concerned,  from  the  rapidly-developing  stenosis  due 
to  recent  cuts  or  gunshot  wounds,  to  edema,  or  to  the  false  membranes 
of  croup,  diphtheria,  and  scarlet  fever,  or  to  the  paralysis  or  spasm  of 


638  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

the  glottis  resulting  from  those  diseases.  The  laryngoscope  is  most 
important  in  both  classes  of  cases  in  order  to  determine  where  trache- 
otomy shall  be  performed  if  symptoms  become  urgent. 

Prognosis  depends  upon  the  cause.  It  is  unfavorable  in  aneurysm, 
mediastinal  tumors,  malignant  tumor,  external  or  internal,  in  some 
forms  of  hypertrophy  of  the  thyroid  gland,  and  in  many  acute  cases 
where  false  membrane  is  formed. 

It  is  favorable  when  there  is  occlusion  by  benign  tumors,  especially 
in  those  so  high  that  they  may  be  reached  through  the  mouth.  The 
prognosis  is  more  favorable  in  all  cases  when  it  is  so  high  that  trache- 
otomy can  be  performed  below  the  obstruction. 

Stenosis  from  paralysis  or  spasm  of  the  laryngeal  muscles  may  be 
hopeful  under  long-continued  treatment  if  a  tracheotomy  be  performed 
to  ensure  comfort  and  safety  to  the  patient. 

Treatment. — Foreign  bodies  must  be  removed  either  through  the 
mouth  or  external  incision.  Benign  tumors  can  be  removed  by  the 
methods  described ;  malign  tumors  are  sometimes  removable. 

Compression  can  be  relieved  only  by  treatment  of  the  cause. 
Tracheotomy  must  often  be  performed  for  false  membrane  or  for  the 
resulting  spasm  or  paralysis  of  acute  diseases.  Adhesions  must  be 
carefully  separated.  The  case  may  even  call  for  laryngectomy.  But 
the  treatment  applicable  to  the  greater  number  of  cases  is  dilatation, 
because  the  large  majority  of  chronic  cases  are  those  resulting  from 
the  contraction  of  cicatricial  tissue  after  syphilitic  ulceration.  Dilata- 
tion is  generally  a  slow  process,  requiring  a  year  or  two  of  persistent 
treatment,  and  tracheotomy,  with  the  wearing  of  a  cannula,  is  pre- 
liminary to  its  successful  carrying  out.  The  common  way  is  to  place 
in  the  canal  a  bougie  as  large  as  will  enter  the  stricture  and  let  it 
remain  for  a  few  minutes.  Gradually  larger  ones  are  borne  for  a 
longer  time.  Various  ingenious  contrivances  for  inserting  and  retain- 
ing them  have  been  made,  and  patients  readily  learn  to  use  these  in- 
struments themselves.  Metal  dilators,  of  two  or  three  blades  for  more 
rapid  work,  are  sometimes  used,  but  because  they  irritate  the  parts  are 
little  to  be  recommended. 

VI.  MALFORMATIONS  OF  THE  LARYNX  AND  TRACHEA. 

In  the  examination  of  the  trachea  and  larynx  of  infants  that  have 
breathed  but  a  short  time  or  not  at  all  a  double  trachea  is  sometimes 
found,  as  if  the  bronchial  tubes  had  extended  themselves  up  to  the 
larynx.  Sometimes  the  trachea  is  divided  in  part  of  its  course  by  a 
septum ;  it  may  contain  diverticula ;  it  may  be  dilated  in  some  parts 
and  constricted  in  others  ;  it  may  open  into  the  esophagus,  or  it  may 
be  entirely  absent. 

A  more  common  congenital  fault  is  an  external  opening  through  the 
integument — a  fistula.  This  is  supposed  to  be  due  to  non-closure  in 
fetal  development  of  the  third  or  fourth  branchial  fissure,  in  which  case 
it  is  most  commonly  unilateral  near  the  sterno-cleido-mastoid  muscle, 
or  it  may  be  accounted  for  by  non-union  of  the  third  or  fourth  branchial 
arch,  when  the  fistula  then  opens  in  the  middle  line.  Sometimes  there 
are  bilateral  fistulae,  one  near  each  sterno-mastoid  muscle,  though  only 


INJURIES  AND  DISEASES   OF   THE   RESPIRATORY  SYSTEM.   639 

a  few  such  cases  have  been  reported.  The  opening  upon  the  integu- 
ment is  usually  very  small,  though  often  internally  it  may  be  seen  by 
laryngoscopic  examination.  Occasionally  the  track  between  the  inter- 
nal and  external  openings  is  very  circuitous.  Sometimes  there  is  no 
external  opening,  and  the  internal  opening  may  manifest  itself  by  an 
emphysematous  condition  of  the  cervical  cellular  tissue.  That  such  a 
condition  is  not  constant  is  explained  by  the  supposition  that  the  open- 
ing is  stopped  by  secretion.  From  the  integumentary  opening  a  drop 
or  two  of  muco-pus  exudes  from  day  to  day,  and  air  on  forced  expi- 
ration. 

Treatment  is  by  caustics,  electrolysis,  or  plastic  operation. 

Tumors  of  the  Trachea. — All  sorts  of  tumors,  benign  and 
malignant,  have  been  found  in  the  trachea.  Their  characters  do  not 
vary  from  such  growths  in  the  larynx,  and  are  more  common  toward 
the  laryngeal  extremity  and  upon  the  membranous  than  the  cartilagi- 
nous portion.  They  occur  most  frequently  in  adult  males.  They  are 
usually  secondary,  and  quite  frequently  are  associated  with  similar 
growths  in  the  contiguous  structures,  the  larynx,  esophagus,  and 
bronchial  tubes. 

Sometimes,  in  tracheotomy,  the  cannula  injures  the  tissues,  or  there 
is  a  subsequent  attrition  of  the  mucous  membrane,  and  on  the  site  of 
such  injuries  fungoid  excrescences  appear.  Also  after  the  wound  from 
such  an  operation  has  cicatrized  there  appear  similar  vegetoid  growths 
upon  the  scar.  The  symptoms  are  the  same  as  for  growths  not  caused 
by  operation. 

As  compared  with  similar  growths  in  the  larynx,  sarcoma  of  the 
trachea  is  relatively  common.     Carcinoma  is  generally  secondary. 

Symptoms. — These  are  substantially  the  same  as  for  laryngeal 
neoplasms — dyspnea,  loss  of  voice,  harsh  cough,  and  pain — when  the 
growth  is  a  carcinoma.  It  is  said  that  carr>'ing  the  head  forward  les- 
sens, and  lying  down  increases,  the  intensity  of  the  symptoms. 

Diagnosis  is  made  from  the  symptoms  and  by  the  exclusion  of 
laryngeal  disease  by  laryngoscopic  examination  or  by  inspection 
through  an  external  incision.  It  is  not,  however,  impossible  to  view 
the  trachea  well  toward  its  bifurcation  if  laiyngeal  tumors  do  not 
obscure  the  field.  Involution  of  the  trachea  from  external  pressure 
must  not  be  taken  for  neoplastic  growths. 

Prognosis  for  benign  tumor  is  good,  for  malignant  very  bad. 

Treatment. — Unless  situated  very  high  in  the  trachea,  treatment 
through  the  mouth  is  impracticable.  Tracheotomy  is  performed, 
and  the  growth  removed  by  the  instrument  suited  to  the  case.  After 
removal  the  site  of  the  growth  is  cauterized.  In  most  cases  if,  after 
tracheotomy,  a  carcinoma  is  discovered,  it  were  better  not  to  attempt 
removal,  but  to  insert  a  cannula,  and  make  the  patient  as  comfortable 
as  possible  by  sedative  drugs.  The  presence  of  carcinoma  in  other 
parts  and  cachexia  would  prevent  any  doubt  as  to  the  character  of  the 
growth,  even  before  tracheotomy. 

Tracheocele  is  a  hernia  of  a  portion  of  the  mucous  membrane  of 
the  trachea  between  the  rings  of  the  trachea  or  through  fistula.  It  may 
be  the  size  of  a  pea  or  as  large  as  an  &^^.  It  is  filled  with  air  and  en- 
larges on  forced  expiration.     It  may  be  almost  or  wholly  negative  as 


640  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

to  symptoms,  or  may  cause  dyspnea,  weakened  voice,  or  the  voice  may 
be  temporarily  lost.  Pressure  will  usually  remove  it  temporarily,  and 
may  do  so  permanently,  though  occasionally  radical  treatment  must  be 
employed  to  effect  a  cure. 

VII.    BRONCHIAL  TUBES. 

Injuries  to  the  bronchial  tubes  are  of  external  origin,  and  are  dis- 
cussed more  properly  under  the  general  Surgeiy  of  the  Chest. 

Tumors  are  generally  malign,  and,  as  a  rule,  are  secondary  to  the 
disease  in  the  lungs,  and,  on  the  whole,  rare. 

Stenosis  of  the  bronchial  tubes  is  not  rare,  and  is  caused  by  sub- 
stances within  the  lumen,  changes  in  the  walls  themselves,  or  by  pres- 
sure outside  of  the  tubes.  A  small  foreign  substance,  as  a  pea  or  bean, 
may  find  its  way  into  the  bronchial  tubes.  Chronic  inflammation  may 
thicken  the  walls,  but,  of  all  agencies  producing  alterations  in  the  sub- 
stance of  the  bronchial  walls  themselves,  infiltration  from  chronic  syph- 
ilis is  the  most  common.  Syphilitic  granulomatous  deposits  occasion- 
ally diminish  the  lumen  of  the  bronchial  tube. 

Mediastinal  tumors,  carcinoma  of  the  lungs  and  lymphatic  glands, 
more  frequently  than  anything  else,  cause  stenosis  of  bronchial  tubes. 

Symptoms  are  not  especially  distinctive,  and  are  apt  to  be  masked 
by  those  of  the  disease  that  causes  the  stenosis.  Dyspnea,  cough,  and 
stridor  are  the  chief  symptoms. 

Treatment. — If  syphilis  is  the  cause,  administration  of  iodid  of  potas- 
sium must  be  pushed.  Nothing  can  be  done  for  carcinoma  except  to 
relieve  pain.  Unless  there  is  a  definite  history,  a  small  foreign  body 
could  not  be  diagnosed ;  it  could  not  well  be  removed,  but  might  be 
coughed  up. 

Tracheotomy. — The  term  "  tracheotomy  "  is  used,  with  less  than 
the  customary  professional  accuracy,  to  indicate  any  operation  that  is 
performed  to  admit  air  to  the  lungs  when  for  any  reason  respiration 
through  the  natural  channels  is  impeded  by  certain  operations  above 
the  trachea.  It  includes  laryngotomy,  crico-thyroid  laryngotomy,  thy- 
roid laryngotomy,  laryngo-tracheotomy,  and  tracheotomy  proper.  The 
two  operations  inexactly  indicated  by  the  word  are  usually  spoken  of 
as  the  high  and  the  low  operation.  By  the  "  high  operation  "  is  meant 
incision  above  the  thyroid  gland  through  the  crico-thyroid  membrane 
and  the  first  ring  of  the  trachea — strictly  a  crico-tracheotomy  or  a 
laryngo-tracheotomy.  The  "  low  operation "  is  below  the  thyroid 
gland,  and  is  through  the  fourth  and  fifth  rings  of  the  trachea,  and 
on  down  to  within  an  inch  of  the  sternum — a  tracheotomy  proper. 
Sometimes  incision  through  the  thyroid  gland  cannot  be  avoided,  and, 
since  it  lies  on  the  second  and  third  rings  of  the  trachea,  this  is  also, 
correctly  speaking,  a  tracheotomy.  Occasionally  in  opening  into  the 
lar)mx  the  thyroid  cartilage  alone  is  incised,  constituting  a  thyroidot- 
omy,  a  thyro-laryngotomy,  or  a  laryngotomy,  any  of  the  three  terms 
correctly  describing  the  location  of  the  incision. 

In  cases  of  croup  and  diphtheria,  and  when  time  and  little  hemor- 
rhage are  the  desiderata,  the  high  operation  is  chosen  by  most  sur- 
geons.    Where  the  operation  may  proceed  in  a  leisurely  manner  and 


INJURIES  AND   DISEASES   OF   THE   RESPIRATORY  SYSTEM.   64 1 

where  permanency  of  opening  is  desired,  the  low  operation  is  selected. 
Generally,  since  it  is  a  highly  vascular  structure,  the  thyroid  gland  is 
avoided.  If  for  any  reason  it  is  desirable  to  make  the  incision  at  that 
portion  of  the  trachea,  the  second  and  third  rings,  where  its  isthmus 
lies,  then  two  ligatures  should  be  passed  around  it,  one  on  each  side 
of  the  median  line,  and  securely  tied. 

The  reasons  for  performing  tracheotomy  are  numerous  and  generally 
imperative.  It  is  done  as  a  precautionary  measure  to  secure  free  respi- 
ration and  to  prevent  the  entrance  of  blood  into  the  air-passages  when 
a  long  and  bloody  operation  is  to  be  done  in  the  mouth  or  pharynx  or 
naso-pharynx.  It  is  done  when  a  foreign  body  is  in  the  larynx,  some- 
times to  give  access  to  air  and  sometimes  to  effect  the  removal  of  the 
foreign  body ;  in  syphilitic  and  tubercular  ulceration  and  in  malignant 
stenosis  of  the  larynx,  to  afford  rest  to  that  organ ;  in  certain  paralytic 
and  spasmodic  affections  of  the  laryngeal  muscles  threatening  suffoca- 
tive dyspnea ;  in  croup,  diphtheria,  and  acute  inflammations  of  the 
larynx  that  greatly  diminish  the  lumen ;  and  in  edema  of  the  glottis. 
So  frequently  has  it  been  mentioned  in  discussion  of  diseases  of  the 
larynx  and  trachea  that  the  student  is  already  familiar  with  the  indica- 
tions  for  its  employment. 

Sometimes  the  necessity  for  tracheotomy  is  so  urgent  that  the  sur- 
geon has  opportunity  for  choice  neither  of  instruments  nor  site.  A 
sharp  penknife  may  be  used,  and  the  shape  of  the  neck,  and  even  the 
attitude  of  the  patient,  may  determine  the  location  of  the  operation. 
If,  as  is  often  the  case  with  children,  the  neck  is  fat  and  short,  the  high 
operation  or  that  through  the  thyroid  gland  will  be  the  only  possible 
one.  If  the  neck  is  long  and  thin,  the  incision  may  be  made  close  to 
the  sternum,  always  in  the  median  line  if  possible,  for  there  hemorrhage 
is  least  and  the  tissues  most  easily  separated.  If,  in  the  hasty  operation 
with  a  life  at  stake,  a  plexus  of  veins  or  an  artery  is  found  crossing  the 
middle  line,  the  risk  must  be  taken  with  confidence  in  stopping  the 
hemorrhage  after  the  immediate  danger  is  past.  If  the  more  leisurely 
operation  is  possible,  such  vessels  may  be  pushed  aside  or  divided 
between  two  ligatures. 

Operation. — Unless  the  patient  is  already  unconscious,  an  anesthetic 
should  be  given  or  cocain  injected  locally.  A  firm  pillow  or  sand-bag 
is  placed  under  the  back  of  the  neck  and  shoulder  so  as  to  stretch  the 
trachea  and  make  it  more  prominent.  An  incision  is  made  in  the  mid- 
dle line,  beginning  at  the  level  of  the  cricoid  cartilage  and  proceeding 
downward  for  a  distance  of  five  to  seven  centimeters.  The  skin,  sub- 
cutaneous tissue,  and  platysma  are  divided ;  the  remaining  muscles  in 
front  of  the  trachea  can  be  separated  by  the  handle  of  the  knife.  The 
left  hand  of  the  operator  now  steadies  the  trachea  while  the  remaining 
tissues  are  dissected  through  and  the  rings  of  the  trachea  exposed. 
All  hemorrhage  having  been  arrested,  a  sharp  hook  or  tenaculum  is 
now  inserted  into  the  trachea  to  bring  it  forward  and  hold  it  steady 
while  it  is  being  opened.  The  rings  of  the  trachea  are  easily  felt  by  the 
point  of  the  finger,  and  cannot  be  mistaken  for  anything  else.  A  sharp- 
pointed  knife  is  the  best  for  making  the  opening,  and  it  should  be 
pushed  through  the  wall  of  the  trachea  with  a  sharp,  quick  thrust,  as 
this  prevents  the  mucous  membrane  from  being  stripped  off  and  carried 

41 


642 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


before  the  point  of  tlie  knife.  Two  or  three  rings  arc  divided  or  the 
cricoid  cartilage  and  one  ring.  As  soon  as  the  windpipe  is  opened  air 
rushes  in,  and  blood,  air,  mucus,  and  perhaps  false  membrane  are  driven 
out  with  each  expiration. 

If  the  operator  is  acting  in  an  emergency  and  has  no  tubes  at  hand, 
all  he  has  to  do  is  to  pass  a  silk  thread  through  the  edge  of  the  tracheal 
wound  and  the  skin  on  either  side.  The  thread  can  be  secured  to  a  piece 
of  elastic  passing  behind  the  neck.  Thus  the  tracheal  wound  can  be 
kept  wide  open. 

Tubes  made  of  aluminum  are  the  lightest,  and  in  that  respect  the 
best.     Those  made  of  hard  rubber  or  silver  are  also  used.     They  are 


Fig.  267. — Gendron's  split  cannula,  silver. 


Fig.  268. — Little's  aluminum  trachea-tube. 


Fig.  269. — Trachea-cannula,  hard  rubber. 


graduated  to  suit  the  size  of  the  windpipe,  and  are  made  double  to  al- 
low of  the  inner  tube  being  withdrawn  and  cleansed  (Figs.  267,  268, 

269).  Selecting  the  largest  tube 
which  the  trachea  can  conveni- 
ently receive,  the  tracheal  w^ound 
is  held  open  either  by  the  silk 
threads  already  mentioned  or  by 
the  handle  of  the  knife  held  trans- 
versely, and  the  tube  slipped  into 
position. 

The  after-treatment  requires  the 
utmost  care.  The  air  of  the  room 
should  be  kept  moist  and  main- 
tained at  a  temperature  of  about 
80°  F.  A  few  folds  of  sterilized  gauze  should  lie  loosely  over  the 
front  of  the  neck  to  filter  the  air  as  it  enters  the  tube.  The  tube  is 
to  be  kept  clear  of  mucus  by  passing  a  damp  feather  through  it  from 
time  to  time,  and  once  or  twice  a  day  the  inner  portion  should  be  taken 
out,  thoroughly  cleansed,  and  returned.  In  cases  of  diphtheria  five  to 
ten  days  is  a  sufficient  time  to  retain  it.  If  the  operation  has  been 
resorted  to  for  the  removal  of  a  foreign  body,  one  or  two  days  will 
suffice.  In  cancer  of  the  lar}mx  or  other  permanent  obstruction  the 
tube  must  be  retained  permanently. 

Intubation  of  the  I^arynx. — Thanks  to  Dr.  O'Dwyer  of  New 
York,  we  have  a  device  which  can  be  employed  without  a  cutting  ope- 
ration, and  which  in  a  large  proportion  of  cases  answers  all  the  purposes 
of  tracheotomy. 


INJURIES  AND  DISEASES   OF   THE   RESPIRATORY  SYSTEM.   643 

Intubation  of  the  larynx  is  indicated  in  diphtheria  and  croup,  in  some 
cases  of  dyspnea  caused  by  burns  and  scalds,  and  in  pressure  upon  the 
larynx  from  tumors.  The  instruments  necessary  for  the  operation  are 
made  in  sets,  and  consist  of  tubes  of  sizes  suitable  for  patients  from 
early  infancy  up  to  twelve  years  of  age  (Fig.  270).  The  proper  tube 
for  each  case  is  found  by  consulting  the  scale  B,  which  indicates  the 
length  of  the  tube  and  the  age  for  which  it  is  suitable.  No  i  is  proper 
for  a  child  up  to  eighteen  months  old ;  No.  2,  between  eighteen  months 
and  three  years  ;  No.  3,  for  the  fourth  year ;  No.  4  from  five  to  seven 
years;  and  No.  5,  from  eight  to  twelve  years.  When  the  tube  is  to  be 
inserted  a  silk  thread  is  passed  through  a  small  hole  near  the  anterior 
angle  of  its  upper  opening.  Should  the  tube  be  placed  in  a  wrong 
position,  it  can  be  withdrawn  by  means  of  this  thread.  The  obturator 
is  next  screwed  into  the  introducing  handle  and  slipped  into  the  tube. 
The  nurse  holds  the  child  upright  on  her  lap  with  its  arms  controlled 
by  a  sheet.     An  assistant  controls  the  little  patient's  head,  and  at  the 


8-12  — 


5-7  — 


Fig.  270. — O'Dwyer's  intubation  instruments:    A,  tube;  B,  scale;   C  mouth-gag;  D,  intro- 
ducer; E,  tube-extractor. 

proper  moment  inclines  it  backward.  The  operator,  seated  in  front, 
inserts  the  gag  {C)  and  opens  the  mouth  as  widely  as  possible.  The 
introducer  is  taken  in  the  right  hand  with  the  silk  thread  looped  around 
the  little  finger.  The  index  finger  of  the  left  hand  is  passed  in  to  the 
epiglottis.  The  epiglottis  is  raised,  leaving  the  glottis  uncovered  and 
ready  to  receive  the  tube.  At  the  same  instant  the  tube  is  passed 
back  to  the  end  of  the  left  finger,  and  by  it  is  guided  into  the  glottis. 
This  is  the  only  difficult  part  of  the  operation.  The  end  of  the  tube 
must  be  kept  exactly  in  the  middle  line ;  it  must  keep  in  close  contact 
with  the  under  surface  of  the  epiglottis,  now  held  upright  by  the  finger; 
the  finger  must  guide  it  to  the  opening,  and  then  move  to  one  side  to 
let  the  tube  pass ;  the  other  end  of  the  handle  is  now  sharply  raised, 
and  the  left  finger  feels  that  the  posterior  wall  of  the  larjmx  is  behind 
the  tube.     The  tube  is  then  pushed  on  to  its  position,  and  by  a  move- 


644  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

ment  of  the  sliding  thumb-piece  on  the  handle  quickly  disconnected  and 
the  handle  and  finger  withdrawn  from  the  mouth.  If  breathing  goes 
on  satisfactorily  through  the  tube,  the  thread  is  withdrawn,  the  index 
finger  again  being  used  to  press  upon  the  upper  end  of  the  tube  and 
prevent  its  withdrawal  while  the  thread  is  pulled  out. 

The  removal  of  the  tube  after  it  has  served  its  purpose  requires  a 
little  skill.  The  patient  is  held  as  before.  The  operator,  taking  the 
extractor  {E^  in  his  right  hand,  introduces  his  left  index  finger,  and, 
guided  by  it,  the  end  of  the  closed  extractor  is  inserted  into  the  open- 
ing in  the  tube ;  by  the  aid  of  the  thumb-piece  the  blades  are  sprung 
apart  and  the  tube  withdrawn. 

Skill  in  the  use  of  these  instruments  can  be  secured  by  practice  on 
the  cadaver,  and  it  is  a  dut}'  which  the  student  owes  himself  and  his 
patients  to  obtain  this  dexterit>'  before  attempting  the  operation  on  the 
living. 

lyaryngectomy. — When  the  larynx  is  the  seat  of  a  sarcoma  or  a 
carcinoma  which  does  not  involve  the  neighboring  tissues  or  glands, 
the  operation  of  lar>'ngectomy  is  indicated.  It  has  also  been  resorted 
to  for  the  relief  of  stenosis  and  of  lupous,  syphilitic,  and  tuberculous 
diseases.     Some  ver>'  satisfactor}'  cases  have  been  reported. 

Operation. — If  there  is  sufficient  time,  a  preliminar>^  tracheotomy 
should  be  made  one  or  two  weeks  before  the  major  operation,  and 
when  practicable  the  tracheal  opening  should  be  high  up,  so  that  it  will 
be  included  in  the  subsequent  incision. 

First  Step  :  The  Incision. — This  should  extend  from  a  little  below 
the  chin  to  within  an  inch  of  the  sternum,  keeping  exactly  in  the  middle 
line  throughout.  The  superficial  tissues  are  divided  and  the  deep  mus- 
cles separated  until  the  lar>mx  proper,  as  well  as  the  membranes  above 
and  below  it,  is  exposed.  The  isthmus  of  the  thyroid  gland  is  divided 
between  ligatures.  Divided  vessels  are  secured  by  forceps  and  afterward 
ligated.  The  lar>mx  is  next  freed  from  the  muscles  and  other  tissues 
which  are  attached  to  it,  provided  they  are  free  from  disease ;  otherwise 
the  dissection  must  go  beyond  the  growth,  so  that  the  diseased  parts 
can  be  removed  with  the  larynx. 

Second  Step  :  Removal  of  the  Larynx. — The  esophagus  is  separated 
from  the  first  ring  of  the  trachea  and  from  the  posterior  surface  of  the 
cricoid  cartilage.  The  esophagus  ends  at  the  upper  border  of  the 
cricoid  cartilage,  and  is  divided  here  when  the  lar>'nx  is  removed.  The 
patient  is  breathing  through  the  tracheal  cannula,  and  it  is  of  great  im- 
portance that  no  blood  be  allowed  to  enter  by  the  side  of  the  instru- 
ment. ]\Iichaers  device  for  this  purpose  is  very  simple.  He  perforates 
a  cylindrical  piece  of  sea-sponge,  moistens  it,  and  then  runs  the  cannula 
through  it.  The  sponge  is  now  allowed  to  dr>%  and  is  surrounded  by 
a  water-tight  membrane  which  is  secured  tightly  by  tying  it  to  the 
cannula  at  the  top  and  bottom.  It  is  then  covered  with  a  solution  of 
gutta-percha.  After  its  insertion  the  sponge  is  moistened  with  an  anti- 
septic lotion  injected  into  it  by  a  hypodermic  syringe.  The  lar>'nx  is 
now  separated  from  the  trachea,  and  to  further  guard  against  the  intake 
of  blood  the  divided  end  of  the  trachea  is  plugged  as  far  down  as  the 
cannula.  The  upper  and  lateral  attachments  of  the  lar>^nx  are  now 
quickly  divided   and  the  lar>-nx  lifted  out  of  its   position.     A  careful 


INJURIES  AND  DISEASES   OF  THE  RESPIRATORY  SYSTEM.  645 

search  is  made  for  diseased  tissue,  and  if  any  remain  it  is  thoroughly 
removed.  The  tracheal  tube  is  left  in  its  former  position  or  it  may  be 
inserted  into  the  upper  end  of  the  trachea. 

Third  Step :  Care  of  the  J  Found. — It  is  best  not  to  close  the  wound, 
but  to  allow  it  to  heal  by  granulation,  which  it  does  with  great  rapidity. 
Packing  with  strips  of  iodoform  gauze  and  careful  tamponade  of  the 
tracheal  tube  are  all  that  is  required.  The  esophagus  having  of  neces- 
sity been  opened,  the  packing  must  be  so  arranged  that  should  the 
patient  vomit  the  whole  of  the  dressing  need  not  be  removed.  At  the 
end  of  two  days  the  patient  is  fed  by  introducing  the  end  of  a  stomach- 
tube  into  the  esophageal  opening,  and  this  will  have  to  be  continued 
for  about  three  weeks,  when  the  tube  can  be  passed  by  the  mouth. 

Much  improvement  to  the  patient's  condition  is  obtained  by  the  use 
of  an  artificial  larynx  made  of  light  metal.  Indeed,  ingenuity  has  gone 
so  far  that  the  new  larynx  is  provided  with  vocal  cords,  by  means  of 
which  the  patient  can  speak  so  as  to  be  heard  and  understood  at  a 
reasonable  distance.  The  successful  cases  in  this  operation  are  25  or 
30  per  cent. 

Unilateral  laryngectomy,  by  which  is  meant  the  removal  of  a  lateral 
half  of  the  larynx,  is  performed  exactly  on  the  same  principles  as  the 
complete  operation.  It  is  less  hazardous,  but,  on  account  of  ,the 
limited  space,  more  difficult  of  performance. 

VIII.   THE   CHEST. 

Wounds  occur  chiefly  as  stabs  or  as  bullet-wounds,  and  their  most 
serious  aspect  is  the  internal  hemorrhage  which  they  produce.  Wounds 
of  the  heart  have  already  been  considered.  When  one  of  the  great 
vessels  is  opened,  the  result  is  generally  speedy  death.  A  wound  of 
the  lung  is  recognized  by  the  patient  expectorating  blood.  Collapse 
of  the  lung  on  one  side  or  the  entrance  of  air  into  the  wound  would 
indicate  that  the  pleura  was  perforated.  Paralysis  of  the  diaphragm 
points  to  division  of  the  phrenic  nerve.  Sudden  collapse  and  death 
would  indicate  the  severance  of  a  large  vessel  or  a  wound  of  the  heart. 
Profuse  external  hemorrhage  is  probably  due  to  a  wound  of  an  inter- 
costal or  the  internal  mammary  arter>^ 

Treatment. — A  wound  of  the  chest  should  not  be  probed,  for  no 
additional  information  can  be  gained  thereby,  and  a  clot  may  be  broken 
up  which  was  doing  good  service  in  arresting  hemorrhage.  The  inter- 
costal arteries  are  not  difficult  to  reach,  and  can  be  ligated.  The  inter- 
nal mammary  lies  about  half  an  inch  from  the  edge  of  the  sternum, 
and  can  be  secured  by  passing  a  curved  needle  around  it  carrjang  a 
ligature.  In  most  cases  patients  who  survive  the  immediate  effect 
of  a  wound  will  hav'e  to  be  treated  on  the  expectant  plan  and  kept 
at  rest. 

Effusions  into  the  Pleural  Cavity. — One  or  both  pleural  cavities 
may  be  more  or  less  filled  with  collections  of  blood,  serum,  or  pus. 
Blood  as  an  effusion  is,  as  a  rule,  the  result  of  a  stab-wound  or  a  trau- 
matism sufficient  to  fracture  a  rib  and  drive  the  fragments  into  the  lung, 
thus  producing  hemorrhage.  When  the  collection  of  blood  is  moder- 
ately large,  coagulation  takes  place  and  the  serum  is  separated  from  the 


646  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

clot.  In  the  course  of  three  or  four  days  the  serum  is  absorbed.  If, 
however,  septic  germs  gain  an  entrance,  suppuration  is  the  result  and 
the  serous  effusion  becomes  a  collection  of  pus  (empyema). 

Much  more  frequently  the  cause  both  of  serous  and  purulent  collec- 
tions in  the  pleural  cavity  is  pleurisy,  and  when  the  ordinary  resources 
of  medical  treatment  prove  unavailing,  the  surgeon  is  called  upon  to 
reliev^e  the  condition  by  operation. 

The  signs  of  a  collection  of  fluid  in  the  pleural  cavity  are  the  same 
whether  the  fluid  be  blood,  scrum,  or  pus.  The  symptoms  are  differ- 
ent ;  if  the  signs  of  an  effusion  come  on  within  a  few  hours  or  even  a 
day  or  two  after  traumatism,  the  effusion  must  be  blood  ;  if  the  signs 
of  effusion  are  preceded  by  an  attack  of  pleurisy,  the  fluid  is  at  first 
probably  serum,  and  later  pus.  The  signs  of  effusion  are  as  follows  : 
There  is  a  history  of  pleurisy  or  of  a  traumatism ;  the  patient  has  a 
tendency  to  lie  on  the  affected  side  ;  that  side  of  the  chest  is  fuller  than 
the  other  side,  because  it  is  distended  with  the  fluid ;  consequently  it 
measures  more.  Place  the  end  of  a  tape  on  the  spinous  processes  be- 
hind and  bring  it  around  to  the  middle  line  of  the  sternum,  and  you 
will  find  a  difference  of  an  inch  or  more  between  the  two  sides.  The 
fluid  bulges  out  the  intercostal  spaces  and  separates  the  ribs  farther 
from  one  another.  The  fluid  pushes  the  heart  to  one  side,  and  it  is  not 
uncommon  to  find  it  on  the  right  side  of  the  chest  when  the  left  pleural 
cavity  is  filled  with  fluid.  Even  the  large,  heavy  liver  is  displaced,  and 
of  course  that  displacement  is  downward.  On  percussion  the  area  oc- 
cupied by  the  fluid  is  as  dull  as  a  board,  and  on  palpation  there  is  no 
friction  or  vocal  fremitus.  What  do  you  hear  on  auscultation  ?  Abso- 
lutely nothing.  In  many  cases  the  level  of  the  fluid  changes  with  the 
position  of  the  patient,  just  as  happens  in  ascites.  Sometimes  there  is 
so  much  fluid  that  there  is  dulness  up  to  the  lev^el  of  the  clavicle.  No 
wonder  that  the  patient  wishes  to  lie  on  the  affected  side,  so  as  to  allow 
the  fluid  to  find  its  lowest  level,  instead  of  pressing  over  against  the 
healthy  lung  and  interfering  with  his  respiration.  The  well  lung  has 
more  to  do  than  it  had  before,  consequently  there  is  exaggerated  ve- 
sicular resonance  heard  on  auscultation.  If  in  spite  of  all  these  signs 
the  surgeon  is  an  unbelieving  Thomas,  he  can  thrust  his  hypodermic 
needle  into  the  side  and  settle  the  question  definitely.  Edema  of 
the  chest-wall  is  considered  an  indication  that  the  contained  fluid  is 
pus. 

Treatment. — The  presence  of  a  considerable  quantity  of  fluid  causes 
compression  of  the  lung,  and  the  longer  this  pressure  continues  the  less 
likely  is  the  lung  to  return  to  its  normal  position.  If  the  fluid  be  pus, 
the  patient  becomes  emaciated  and  falls  into  that  train  of  symptoms  which 
we  if  necessary  sum  up  in  the  one  word — hectic.  For  the  simple  re- 
moval of  fluid  the  operation  of  paracentesis  thoracis  is  resorted  to.  This 
was  formerly  done  by  a  simple  trocar  and  cannula,  but  Dr.  Bowditch 
greatly  improved  upon  this  method  by  the  invention  of  the  syringe 
which  bears  his  name  and  which  has  led  to  the  various  forms  of  aspi- 
rators. In  the  withdrawal  of  fluid  the  two  points  to  be  kept  in  view  are 
to  get  rid  of  the  fluid  as  thoroughly  as  possible  and  to  prevent  the  en- 
trance of  septic  germs,  either  on  the  needle  or  by  the  entrance  of  air. 
The  aspirating  needle  and  the  skin  over  a  considerable  area  should  be 


INJURIES  AND  DISEASES   OF   THE   RESPIRATORY  SYSTEM.   647 


as  carefully  sterilized  as  for  a  laparotomy.  The  opening  made  by  the 
needle  should  afterward  be  closed  by  iodoformized  collodion  and  ab- 
sorbent cotton.  The  most  suitable  place  to  insert  the  needle  is  just 
below  the  lower  angle  of  the  scapula  or  at  the  side  of  the  chest  just  in 
front  of  the  latissimus  dorsi  muscle.  If  the  fluid  is  found  to  be  serous, 
the  prospect  of  its  not  returning  is  fairly  good ;  if  it  is  purulent,  further 
operative  procedures  will  almost  surely  be  required. 

Thoracotomy. — An  empyema,  like  a  collection  of  pus  anywhere 
else,  should  be  treated  by  incision  and  drainage.  The  simplest  opera- 
tion consists  in  making  an  incision  about  two  inches  in  length  over  the 
eighth  or  the  seventh,  or  even  as  high  as  the  sixth,  intercostal  space  and 
just  in  front  of  the  latissimus  dorsi  muscle.  The  skin  is  drawn  upward, 
so  that  the  opening  will  be  valvular.  Dissecting  through  the  thoracic 
wall,  the  pleura  is  reached,  and  to  be  on  the  safe  side  an  aspirating 
needle  is  thrust  into  it.  If  pus  escape,  the  pleura  is  then  incised  to  the 
length  of  about  an  inch.  Two  drainage-tubes  are  inserted  side  by  side. 
When  necessary  the  pleural  cavity  can  be  washed  through  these  tubes. 

It  often  happens  that  the  ribs  are  close  together  and  compress  the 
rubber  drainage-tubes,  rendering  them  useless.  The  proper  thing  to 
do  under  these  circumstances  is  to  resect  a  piece  of  the  rib  (about  an 
inch),  and  the  seventh  is  generally  the  one  chosen. 

Thoracoplasty,  or  Estlander's  Operation. — In  favorable  cases  the 
pus-cavity  is  drained  away,  and  the  lung,  expanding  to  its  former  posi- 
tion, fills  the  pleural  cavity  once  more.  It  often  happens  that  our  hopes 
in  this  respect  are  disappointed  ;  the  empyema  continues  and  the  lung 
remains  collapsed.  It  then  comes  to  be  a  question  of  Mohammed  going 
to  the  mountain,  since  the  mountain  refuses  to  come  to  the  prophet. 
Estlander's  operation  is  designed  to 
cause  the  chest-wall  to  fall  in  to  meet 
the  lung. 

In  the  simpler  class  of  cases  it  is  only 
necessary  to  make  an  incision  from  the 
axilla  downward  and  remove  pieces  from 
the  third  to  the  eighth  rib.  In  the  more 
obstinate  cases  it  is  necessary  to  make 
an  incision  both  in  front  and  behind,  re- 
moving so  much  of  the  ribs  as  is  requi- 
site to  cause  the  required  "  staving  in." 

In  old  intractable  cases  Schede  has 
devised  a  still  more  radical  operation. 
He  made  an  incision  from  the  level  of 
the  axilla  in  front,  sweeping  downward 
in  the  form  of  an  ellipse  to  the  lower 
limb  of  the  pleura  and  ending  at  the 
second  rib  behind  (Fig.  271).  The  flap 
is  dissected  upward  and  the  scapula 
lifted  from  the  trunk.  The  ribs,  the 
entire  muscular  wall,  and  the  pleura 
are  removed  from  the  second  rib  down- 
ward, the  line  of  section  being  in  front  at  the  cartilage  and  posteriorly 
at  the  tubercles.     The  cavity  is  then  curetted  and  the  flaps  replaced. 


Fig.  271. — Incision  for  Schede's  ope- 
ration of  thoracoplasty  (Esmarch  and 
Kowalzig). 


648 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


This  is  a  serious  operation.    In  a  case  requirini^  less  surface  of  chest- 
wall  I  make  a  less  extensive  incision,  as  seen  in  Fig.  272. 


f'iG.  272. — Result  of  thoracoplastic  operation. 


CHAPTER  XII. 

THE   DIAGNOSIS  AND   TREATMENT   OF   SYPHILIS. 

Modes  of  Transmission. — Syphilis  is  an  hereditary  disease,  but  it 
does  not  by  any  means  follow  that  all  the  children  of  parents  who  are 
one  or  both  tainted  with  syphilis  shall  be  syphilitic.  According  to  the 
law  of  Profeta  (sometimes  called  Profeta's  immunity),  the  children  of 
such  parents  may  be  born  healthy,  remain  healthy,  and  be  all  their 
lives  proof  against  syphilis  as  if  they  had  at  one  time  suffered  from 
the  disease.  This  immunity  is  explained  on  the  ground  that  the  tissue- 
products  of  the  virus  pass  into  the  fetal  blood  and  protect  the  system 
against  future  contamination  ;  just  as  vaccine  virus  protects  against 
small-pox.  The  mother  of  syphilitic  children,  who  have  inherited  the 
disease  from  a  tainted  father,  may  herself  remain  free  from  the  disease. 
This  is  known  as  Colles'  immunity,  and  is  accounted  for  by  assuming 
that  the  tissue-products  of  the  virus  have  passed  from  the  fetal  into  the 
maternal  circulation  and  protected  the  mother. 

As  a  general  rule,  syphilis  is  contracted  by  impure  sexual  inter- 
course, but  it  must  not  be  forgotten  that  the  disease  is  frequently 
acquired  or  transferred  by  other  avenues.  It  may  be  contracted  by 
kissing,  by  smoking  an  unclean  pipe,  or  by  drinking  out  of  a  contam- 
inated vessel.     The  surgeon,  accoucheur,  or  nurse  runs  a  risk  in  the 


THE  DIAGNOSIS  AND    TREATMENT  OF  SYPHILIS.  649 

discharge  of  professional  duties,  and  there  is  danger  every  time  an 
abraded  surface  comes  in  contact  with  instruments  or  other  articles 
contaminated  with  the  syphilitic  virus. 

The  diagnosis  of  syphilis  is  greatly  simplified  by  dividing  the  disease 
into  stages,  as  follows  : 

1.  The  stage  of  incubation.  This  is  the  period  which  intervenes 
between  the  time  of  exposure  to  the  virus  and  the  first  appearance  of 
the  initial  sore. 

2.  The  period  of  primary  symptoms,  in  which  chancre  and  affections 
of  the  adjacent  glands  appear. 

3.  This  is  a  period  of  repose.  It  lasts  about  six  weeks,  and  during 
this  time  the  virus  is  incubating  for  the  secondary  symptoms.  It  is 
sometimes  called  the  period  of  secondaiy  incubation. 

4.  Secondary  symptoms,  characterized  by  mucous  patches,  erythem- 
atous, pustular,  papular,  and  tubercular  affections  of  the  skin.  This 
period  may  last  from  one  to  three  years. 

5.  The  secondary  symptoms  may  subside,  and  under  proper  treat- 
ment the  patient  may  be  apparently  cured,  but  it  is  by  no  means  cer- 
tain that  the  varus  is  entirely  exhausted.  He  must  be  kept  under  ob- 
servation for  a  period  varying  from  two  to  four  years.  During  this 
time  his  children,  if  any  are  born  to  him,  are  likely  to  be  syphilitic. 
At  the  end  of  the  fourth  year  one  of  two  points  is  settled — either  that 
he  has  been  cured  or  that  he  has  entered  upon  another  stage  of  the 
disease — viz.  the  period  of  tertiary  syphilis,  which  is  unlimited  in  dura- 
tion. The  bones  now  suffer,  and  we  find  periostitis,  osteitis,  nodes,  etc. 
Gummata  are  found  in  one  or  more  parts  of  the  body,  and  there  are 
tuberculo-ulcerous  syphilides  of  the  skin. 

No  two  cases  of  syphilis  are  exactly  alike,  and  yet  the  family  like- 
ness is  marked  in  all.  The  whole  category  of  syphilitic  manifestations, 
protean  in  their  form  and  irregular  in  their  clinical  history,  possess  cer- 
tain peculiarities  that  belong  to  no  other  class  of  eruptive  diseases. 
When  called  upon  to  differentiate  the  lesions  peculiar  to  the  secondary 
or  tertiary  stage  of  this  malady,  no  part  of  the  body  should  escape 
inspection.  The  closest  scrutiny  should  be  made  of  old  scars,  alopecia, 
enlarged  glands,  gummata,  mucous  patches,  condylomata  of  the  genital 
and  anal  regions,  ulceration  of  the  phar\mx,  iritis,  and  macular  eruptions. 

The  Primary  Sore — Hard  Chancre. — At  the  end  of  the  period 
of  incubation,  which  is  never  before  the  tenth  day  and  may  be  pro- 
longed to  or  beyond  the  thirtieth,  the  "  initial  lesion,"  "  primary  sore," 
or  "  hard  chancre  "  begins  to  appear.  It  is  an  abrasion,  an  erosion,  or 
a  papule  that  subsequently  breaks  down  and  ulcerates.  Its  shape  is 
round  or  oval.  Its  edges  are  slanting  and  adherent  to  the  tissue 
beneath  them.  The  discharge  is  scanty  and  serous  unless  the  sore  has 
been  irritated.  Its  base  is  indurated,  but  it  must  be  borne  in  mind  that 
the  peculiar  induration  which  has  earned  for  it  the  name  of  "  hard 
chancre "  is  caused  by  cell-proliferation,  and  is  not  fully  developed 
before  the  tenth  to  the  fourteenth  day.  The  chancre  is  painless. 
Within  a  week  the  glands  become  indurated.  The  inflammation  is 
indolent,  and  there  is  no  tendency  to  suppurate.  The  sore  is  usually 
solitary ;   if  several  lesions  appear,  they  come  simultaneously. 

The  dias:nosis  between  "  hard  "  and  "  soft  "  chancre  is  of  the  utmost 


650  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

importance.  A  soft  chancre  or  chancroid  has  a  short  period  of  incu- 
bation ;  it  appears  ///  from  tzvciity-four  Jioiirs  to  eight  days.  Chancroid 
makes  its  appearance  as  a  pustule.  Its  shape  is  round  or  oval ;  its 
edges  present  the  appearance  of  having  been  punched  out  and  under- 
mined; the  discharge  is  creamy  and  puriform ;  its  base  is  soft  and 
supple,  tender,  and  at  times  exquisitely  painful  upon  pressure.  The 
ulcer  follows  the  natural  anatomical  lines  or  folds  of  the  integument. 
It  is  frequently  complicated  with  bubo  and  inclined  to  suppurate. 

The  following  table  presents  the  differential  diagnosis  between 
chancre  and  chancroid : 

Chancre.  Chancroid. 

Cause. — Syphilitic  germ  or  virus.  Inoculation  by  the  secretion  of  chancroid. 

Incitbation. — Ten  to  thirty  days ;  average  First  symptom  makes  its  appearance  in  three 
three  weeks.  to  seven  days.     Sometimes  within  twenty- 

four  hours. 

Nzcmber  of  Lesions. — Usually  solitary ;  when  Usually  more  than  one  after  appearing  sue- 
more  than  one,  all  appear  at  the  same  time.  cessively,  by  auto-inoculation. 

Color. — Dull,  sometimes  red  or  dirty  white ;  Dirty  yellowish  color,  like  wet  chamois  skin, 
secretion  serous  and  scanty,  frequently  Secretion  purulent  and  profuse,  not  inclined 
scales.  to  the  formation  of  scales ;  the  surface  is 

always  moist. 

Subjective  Syviptonis. — Pain  usually  absent ;     Exquisitely  tender,  especially  on  pressure, 
not  much  tenderness  on  pressure. 

Indta-ation. — Base  of  ulcer  hard  and  inelastic     Base  of  ulcer  pliable  ;  no  induration, 
by  the  tenth  day. 

Edges. — Sloping  and  adherent.  Present     the     appearance    of    having    been 

punched  out ;   frequently  undermined. 

Glands. — Both  sides  indolent;  not  inclined  More  often  one  side  affected  and  inclined  to 
to  suppurate.  suppurate.     In  about  one-third  of  all  cases 

a  bubo  is  present. 

Treatment. — Apart  from  cleanliness,  local  Local  applications  the  all-important  treatment, 
treatment  is  of  no  importance.  Internal  medication  is  of  no  use. 

The  chancre  must  be  differentiated  from  herpes  progenitalis, 
balanitis,  venereal  warts,  epithelioma,  and  chancroid. 

The  herpetic  lesion  differs  from  that  of  syphilis  in  its  multiplicity 
and  in  its  vesicular  and  transitory  nature,  and,  like  balanitis,  in  yielding 
quickly  to  treatment ;  also,  as  in  balanitis,  there  is  no  ulceration,  no 
induration,  and  no  glandular  complications. 

Venereal  warts  differ  from  chancres  in  that  they  are  more  indurated, 
seldom  ulcerate,  are  not  accompanied  by  adenopathy,  and  are  more 
persistent.     They  are  rarely  found  in  other  than  the  progenital  region. 

Epithelioma  usually  occurs  after  middle  life  in  both  sexes,  whereas 
syphilis  is  more  often  observed  in  young  adults,  and  the  lesion  of  epi- 
thelioma is  usually  far  more  persistent  than  that  of  syphilis,  and  is  gen- 
erally found  in  the  glans  penis,  presenting  the  appearance  of  a  flattened 
papule,  a  shallow  erosion,  or  a  warty  elevation.  It  may  be  accompanied 
by  induration  and  adenopathy,  but  is  usually  inactive  and  only  affects 
the  glands  in  the  advanced  stage  of  the  disease. 

Treatment  of  CJiancroid. — There  are  two  methods  of  treatment.  The 
first  relies  upon  cleanliness  and  the  local  application  of  antiseptic  rem- 
edies. This  is  frequently  all  that  is  required  to  arrest  the  destructive 
action  of  the  peculiar  microbe  and  the  further  progress  of  the  lesion. 
Many  surgeons  never  omit,  in  any  case,  to  adopt  the  second  method, 
cauterization,  which  aims  to  destroy  at  once  the  germs  and  convert  the 


THE  DIAGNOSIS  AND    TREATMENT  OF  SYPHILIS.  65 1 

chancroid  into  a  healthy  sore.  It  is  quite  necessary  that  all  irregular 
habits  of  life  should  be  duly  corrected,  and  when  the  lesion  is  serious 
and  other  complications  threaten,  the  recumbent  position  should  be  rig- 
idly enforced.  In  simple  cases,  occurring  in  patients  otherwise  healthy 
and  robust,  no  internal  medication  is  required.  In  other  cases,  that  are 
weakened  by  excesses  or  disease,  it  will  be  proper  to  administer  tonics 
and  direct  attention  to  all  the  details  that  will  improve  the  general 
health. 

The  antiseptic  treatment  of  the  disease  consists  in  keeping  the  ulcer 
thoroughly  clean  by  washing  it  with  soap  and  warm  water,  followed  by 
an  irrigation  of  dilute  peroxid  of  hydrogen,  sublimate  solution  (i :  2000), 
carbolic  acid  (i  :  40),  or  the  application  of  lint  which  has  been  previously 
wet  in  either  of  the  latter  two.  The  ulcer  should  be  completely  cov- 
ered, and  in  no  case  must  it  be  allowed  to  lie  in  contact  with  the  healthy 
mucous  membrane  or  skin,  as  the  parts  are  sure  to  become  infected  and 
new  lesions  are  certain  to  appear.  This  precaution  must  be  carefully 
observed  in  females :  the  walls  of  the  vagina  and  vulva  should  at  all 
times  be  separated  by  the  interposition  of  lint  or  absorbent  cotton  pre- 
viously wet  with  one  of  the  above  solutions.  These  should  be  changed 
at  intervals  of  two  or  three  hours. 

Many  surgeons  prefer  to  keep  the  ulcer  thoroughly  cleansed  by  fre- 
quent ablutions  of  antiseptic  solutions  and  apply  to  it  a  powder,  consti- 
tuting a  dry  method  as  opposed  to  the  wet  or  moist  dressing.  For  this 
purpose  iodoform,  hydronaphthol,  aristol,  acetanilid,  and  calomel  are  val- 
uable. Iodoform  undoubtedly  occupies  the  first  place  as  the  most  potent 
agent  that  can  be  applied ;  its  power  to  overcome  the  microbe  of  chan- 
croid is  second  to  none  ;  its  chief  objection  is  its  odor  :  if,  however,  care 
be  taken  in  its  application  to  prevent  its  falling  on  the  clothing,  scarcely 
any  odor  will  be  noticed.  A  very  good  plan  is  to  make  an  ethereal 
solution  and  spray  it  on  the  ulcer ;  the  ether  will  speedily  evaporate, 
leaving  a  thin  film.  Care  must  be  taken  that  the  undermined  edges  are 
thoroughly  reached.  When  the  floor  of  the  chancroid  loses  its  dirty 
yellowish  appearance  and  becomes  red  and  filled  with  healthy  granula- 
tions, the  application  of  iodoform  may  be  omitted,  and  the  use  of  mild 
odorless  antiseptics  substituted. 

For  the  purpose  of  cauterization  the  actual  cautery  or  chemical 
agents  may  be  employed.  The  actual  cautery  is  preferable  if  it  is  con- 
venient ;  if  not,  nitric  acid  or  carbolic  acid  can  be  used.  The  ulcer 
should  be  thoroughly  cleansed  and  carefully  dried ;  a  4  to  8  per  cent, 
solution  of  cocain  is  then  applied  to  the  surface  of  the  ulcer  or  a  few 
drops  may  be  injected  subcutaneously  beneath  the  base.  Care  must 
be  observed  that  every  part  of  the  lesion  is  brought  in  contact  with  the 
cautery.  After  cauterization,  lead-water  dressings  are  applied,  and  the 
patient  put  to  bed  until  the  reaction  has  subsided.  Cauterization  is 
becoming  less  frequently  used  than  formerly ;  it  often  fails  to  arrest  the 
progress  of  the  lesion ;  the  sore  assumes  a  fierce  and  obstinate  aspect, 
and  the  pain  and  soreness  are  greatly  increased.  Cauterization,  there- 
fore, as  a  routine  practice  should  be  condemned.  In  all  cases  where 
the  ulcer  is  intractable  with  pain,  swelling,  phimosis,  and  paraphimosis, 
the  parts  should  be  submerged  in  hot  boric-acid  water  for  hours  at  a 
time.     In  the  female  the  vagina  should  be  frequently  and  repeatedly 


652  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

irrigated  with  a  saturated  solution  of  boric  acid  as  hot  as  can  be  borne. 
In  the  treatment  of  phagedena,  phimosis,  and  paraphimosis  no  more 
potent  and  effectual  remedy  can  be  adopted  than  hot  water ;  hot  sitz- 
baths  may  be  employed,  the  patient  spending  the  greater  part  of  his 
time  in  the  bath.  The  vitality  of  tlie  microbe  is  destroyed  by  the  per- 
sistent use  of  water  at  a  moderately  high  temperature. 

Some  authorities  advise  incision  of  the  prepuce  for  the  relief  of  phi- 
mosis or  paraphimosis.  This  procedure  should  not  be  adopted  until 
the  measures  already  mentioned  have  been  tried,  as  it  is  almost  im- 
possible with  the  greatest  attention  to  antisepsis  to  prevent  the  infec- 
tion of  the  wounds.  Should  an  incision  be  made,  the  chancroid 
should  previously  be  cauterized,  as  also  the  wounds  as  soon  as  they 
are  made. 

Bubo  not  infrequently  complicates  chancroid.  It  may  be  of  an  in- 
dolent, non-suppurating  character  or  it  may  assume  the  virulent  type. 
It  is  well  to  emplo)'  the  usual  remedies  to  combat  suppuration,  as  pres- 
sure with  a  spica  bandage,  rest  in  the  recumbent  position,  iodin  exter- 
nally or  a  solution  of  iodoform  in  collodion  frequently  applied  to  the 
swelling.  The  proper  strength  is  iodoform  13,  collodion  15.  Injec- 
tions of  various  antiseptics  into  the  bubo  itself  have  been  followed  by 
dangerous  results,  and  are  not  usually  effectual.  When  it  becomes 
obvious  that  suppuration  has  taken  place  or  when  further  intervention 
is  ineffectual,  free  incision  should  be  made  with  careful  antiseptic  pre- 
cautions, all  glandular  tissue  wholly  or  in  part  involved  should  be  re- 
moved, the  parts  curetted  if  necessary,  washed  with  hot  boric-acid  solu- 
tion, and  dressed  with  iodoform  gauze. 

Treatment  of  chancre  consists  in  cleanliness  ;  in  the  majority  of  cases 
no  other  treatment  is  necessary.  Small  pieces  of  lint  made  moist  by 
dipping  them  in  solutions  of  sublimate  and  frequently  changed,  calomel 
lightly  dusted  upon  the  ulcer,  unguentum  hydrargyri,  aristol,  and  iodo- 
form are  all  appropriate.  In  women  the  labia  should  be  well  separated 
by  pledgets  of  lint.  Buboes  complicating  chancres  are  best  treated  by 
frequent  ablutions  of  hot  water,  followed  by  the  inunction  of  mercurial 
ointment.  The  habits  of  the  patient  should  be  regulated  to  comply 
with  the  strictest  rules  of  hygiene.  In  general,  it  is  best  to  withhold 
specific  medication  until  the  appearance  of  secondary  manifestations, 
since  the  early  exhibition  of  these  remedies  has  a  tendency  to  retard  to 
a  remarkable  degree  the  appearance  of  these  lesions. 

Syphilis  has  no  respect  for  any  of  the  tissues  of  the  body :  the  in- 
tegument, the  bones,  the  viscera,  and  connective  tissue  are  all  liable  to 
become  invaded. 

The  Secondary  Stage. — We  have  seen  that  the  period  of  primary 
incubation  occupies  from  ten  to  thirty  days  or  more.  The  chancre  and 
its  attendant  glandular  swellings  have  taken  their  course,  and  the  period 
of  secondary  incubation  is  going  on.  There  is  no  stated  period  at  which 
the  chancre  disappears.  It  may  persist  until  after  the  evolvement  of 
systemic  symptoms  or  terminate  earlier.  It  terminates  in  simple  reso- 
lution except  in  those  cases  which  ulcerate,  and  in  these  a  characteristic 
scar  remains. 

The  invasion  of  the  different  tissues  of  the  body  by  the  syphilitic 
virus  is  very  slow  and  insidious,  and  during  the  early  part  of  the  sec- 


THE   DIAGNOSIS  AND    TREATMENT  OF  SYPHILIS.  653 

ondary  incubation  giv^es  no  evidence  of  its  presence.  During  the  latter 
part,  however,  within  a  week  or  two  before  the  eruption,  the  patient 
exhibits  not  infrequently  a  sallow  complexion,  and  still  later  a  marked 
degree  of  pallor.  He  complains  of  malaise  and  lassitude,  loss  of  sleep 
and  appetite,  and  a  depression  of  mind  and  body.  He  has  pains  in  the 
muscles  and  bones,  and  perhaps  effusion  into  the  knee-  and  elbow-joints. 
Just  preceding  the  eruption  there  is  an  elevation  of  temperature ;  this 
is  the  syphilitic  fever.  The  temperature  is  rarely  high  unless  the  erup- 
tion is  to  be  of  a  pustular  nature.  It  ranges  from  101°  to  103°  F.,  some- 
times 104°  or  105°  F.  This  fever  endures  for  several  days,  possibly 
for  weeks.  A  short  time  before  the  eruption  the  superficial  glands 
become  enlarged  and  constitute  an  important  element  in  diagnosis. 
The  extent  and  general  involvement  of  these  glands  are  in  proportion 
to  the  severity  or  malignancy  of  the  disease,  and  also  to  the  suscepti- 
bility of  the  patient  to  the  influence  of  the  poison.  The  glands  most 
frequently  involved  and  conspicuous  are  the  submaxillary,  submental, 
occipital,  femoral,  and  the  anterior  and  posterior  auricular.  These  vary 
in  size  from  a  pea  to  a  small  hickory-nut ;  they  are  movable,  indolent, 
and  painless.  Within  a  few  days  a  rash  appears,  usually,  though  not 
always,  in  the  form  of  roseola,  and  is  frequently  so  mild  that  it  is  over- 
looked by  the  patient  and  even  by  the  medical  attendant. 

The  lesions  of  secondary  syphilis  are  inclined  to  be  superficial  and 
confined  to  the  integument;  they  are  somewhat  rapid  in  their  develop- 
ment and  progress  as  compared  with  lesions  of  the  tertiary  stage.  They 
are  also  more  symmetrical,  show  a  more  benign  disposition,  and  are 
more  easily  influenced  by  specific  medication.  This  stage  includes 
those  lesions  of  the  skin  that  are  described  as  erythematous,  papular, 
pustular,  and  vesicular  syphilis. 

The  syphiloderm  may  be  confounded  with  all  other  known  affec- 
tions of  the  skin.  While  they  are  not  confined  to  any  particular  por- 
tion of  the  integument,  the  different  forms  of  eruptions  exhibit  a  marked 
preference  for  certain  localities.  On  account  of  their  close  resemblance 
to  the  non-specific  affections  of  the  skin  they  demand  careful  study  and 
consideration. 

The  following  points  should  be  observed :  their  color,  situation,  pig- 
mentation, polymorphism,  absence  of  subjective  symptoms,  grouping 
and  shape  of  lesion.  No  single  case  of  syphilis  will  be  likely  to  in- 
clude all  of  these  distinctive  features,  and  neither  of  them,  taken  singly, 
would  justify  a  diagnosis  of  syphilis  ;  taken  together,  they  constitute  a 
complete  index  to  the  character  of  the  malady  in  question.  They  are 
essentially  chronic,  and  are  not  generally  accompanied  by  even  a  mod- 
erate degree  of  inflammation. 

Color. — In  their  early  stages  they  are  of  a  bright-pink  or  pinkish- 
red  tint,  but  not  so  red  as  is  common  in  exanthemata.  The  older  they 
become  the  more  they  fade,  until  they  assume  a  brownish-red,  copper, 
or  raw-ham  color.  Pressure  upon  the  early  lesions  causes  them  to 
disappear,  but  later,  when  they  have  acquired  the  copper  color,  it  be- 
comes permanent.  It  should,  however,  be  remarked  that  the  natural 
complexion  of  the  patient  modifies  to  a  great  extent  the  appearance  of 
the  lesion.  In  the  blonde  it  is  red,  in  the  brunette  it  is  brownish  red, 
and  in  persons  who   are  broken  down,  pallid,  and  cachectic  there  is 


654  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

more  of  a  li\'icl  purple  hue.  Upon  the  lower  limbs  in  nearly  all  cases 
the  color  is  darker  than  upon  the  trunk  and  upper  extremities. 

Location. — Syphilitic  eruptions  show  a  preference  for  certain  parts 
of  the  body  where  non-specific  eruptions  do  not  often  develop.  They 
are  common  upon  the  scalp  about  its  junction  with  the  forehead,  at  the 
angles  of  the  mouth,  upon  the  nose,  about  the  anus  and  genitals,  upon 
the  palms  and  soles,  and  in  the  groin. 

Po/ftnorphisJii. — In  non-specific  eruptions  of  the  skin  there  is  usually 
a  uniformity  in  the  type  of  the  eruption.  In  syphilis  it  is  quite  common 
to  find  er>'thematous,  papular,  and  pustular  lesions  on  different  parts 
of  the  body  at  the  same  time. 

S?di/a-tirc  Sjii/ptouis. — The  lesions,  owing  to  their  indolent,  chronic, 
and  non-inflammatory  character,  do  not  excite  much  distress.  Pain 
and  itching  are  usually  absent. 

Mucous  Patches. — On  mucous  membranes  syphilis  assumes  a  form 
which  is  very  characteristic.  When  a  papule — that  is,  an  inflammatory 
swelling  of  the  corium  and  papillae — occurs  upon  a  mucous  surface  and 
is  subjected  to  constant  moisture  and  warmth,  the  epithelium  becomes 
macerated  and  disappears.  The  surface  occupied  by  the  papule  be- 
comes broader  and  its  color  changes.  Sometimes,  as  on  the  palate  or 
lips,  the  mucous  patch  has  a  whitish  appearance,  as  if  it  had  been 
touched  with  nitrate  of  silver.  In  the  skin  it  is  red  and  shining.  The 
shape  is  circular  or  oval  and  the  epidermis  is  thickened.  The  appear- 
ance of  mucous  patches  is  such  that  when  once  seen  they  cannot  be 
mistaken  for  anything  else. 

The  nails  should  always  be  examined  in  syphilis.  Inflammation 
around  them  occurs  in  two  forms,  the  dry  and  the  moist,  and  occasion- 
ally results  in  their  dropping  off 

Irregularity  in  the  Evolution  of  Syphilis. — In  many  cases  the 
course,  character,  and  duration  are  extremely  mild ;  the  secondary 
manifestations  are  so  simple  and  yield  so  readily  to  treatment  that  this 
form  has  been  called  "  benign  syphilis."  In  other  cases  from  the  com- 
mencement of  the  initial  lesion  the  progress  of  the  disease  is  rapid,  the 
lesions  develop  precociously,  the  secondary  stage  is  wanting,  and  the 
tertiary  stage  appears  instead.  It  is  fierce  and  intractable ;  its  ravages 
are  frightful  and  hideous  to  observe.  All  efforts  to  arrest  its  onward 
march  are  unav^ailing,  and  the  unfortunate  victim  yields  the  palm  to  the 
Mephisto  of  all  diseases  that  afflict  mankind. 

Syphilides  appear  in  two  forms,  the  dry  and  the  moist.  In  diagno- 
sis the  most  common  source  of  error  is  between  syphilitic  tubercles  and 
lupus  vulgaris.  The  following  table,  from  A)i  American  Text-Book  of 
Surgery,  is  valuable : 

Tubercular  Syphilide.  Lupus  Vulgaris. 

Occurs    chiefly  among   adults ;    considerable     Occurs  commonly  in  young  persons  ;  when  in 
infiltration  of  skin.  adults  there   is  often  history  of   a  similar 

eruption  in  childhood. 
Tubercles  opaque  and  of  deep  brownish-red     Not  so  marked.     Tubercles  often  translucent 

color.  and  lighter  in  color. 

The  characteristic  ulcer  produced  in  a  month     The  same  amount  of  ulceration  would  require 
or  two.  several  months,  or  even  years,  for  its  devel- 

opment. 


THE   DIAGNOSIS  AND    TREATMENT  OF  SYPHILIS.  655 

Tubercular  Syphilide.  Lupus  Vulgaris. 

Ulcers  usually  distinct.  Ulcers  apt  to  be  confluent. 

Ulcers  deep  and  extensive.  More  superficial  and  involving  smaller  area. 

Ulcers  small,  circular,  and  punched  out.  No  regular  form  or  perpendicular  edges. 

Secretion  copious  and  sometimes  oftensive.  Secretion  slight  and  inofiensive. 

Crusts  bulky  and  greenish.  Crusts  thin  and  dark-colored. 

Scales  irregular  in  shape  and  attachment.  Scales  arranged  more  regularly,  attached  in 

the  center  and  loosened  at  the  edges. 

Cicatrices  soft,  white,  circular.  Cicatrices  distorted,  irregular,  puckered. 

History  and  concomitant  symptoms  of  syph-  No  history  except  as  a  coincidence. 

ills. 

Local  treatment  ineffective ;  internal  specific  Eruption  disappears  only  under  very  active 

treatment  effects  a  cure.  lucal  treatment,  as  curetting,  or  under  the 

influence  of  tuberculin. 

The  Tertiary  Stage. — Tertiary  lesions  do  not  manifest  them- 
selves, as  a  rule,  before  the  third  or  fourth  year,  and  in  a  large  pro- 
portion of  cases  do  not  develop  at  all.  Their  early  appearance 
signifies  a  severe  type  of  the  malady.  This  stage  includes  those 
lesions  that  are  usually  termed  tubercular,  bullous,  ulcerative,  and 
gummatous  syphilides.  They  are  slow  and  indolent  in  their  develop- 
ment and  course,  deep-seated,  intractable  to  treatment,  show  a  lack  of 
symmetry,  are  scantily  distributed,  and  are  often  terribly  distinctive. 
The  lesions  of  the  secondary  stage  are  found  to  be  superficial ;  those 
of  the  tertiary  period  are  deep.  To  give  them  in  detail  would  be 
beyond  the  scope  of  this  work,  for  they  involve  almost  every  organ 
and  tissue  in  the  body,  and  have  been  referred  to  as  these  organs  have 
been  discussed.     A  brief  summary  is  all  that  can  be  given : 

\.  Tiibcratlm'  syphilides  are  large  and  greatly  hypertrophied  papules, 
and  stand  upon  the  borderland  between  the  secondary  and  tertiary 
stages.  They  are  flattened  pimples  attended  with  a  thickening  of  all 
the  tissues  of  the  skin.     They  occur  singly  or  in  groups. 

2.  Giunniata  are  almost  identical  with  tubercles,  but  have  these  dis- 
tinctions :  they  go  beyond  the  skin  and  involve  the  subcutaneous  cellu- 
lar tissue ;  they  make  their  appearance  at  any  time  between  the  first 
and  the  thirtieth  year  after  the  appearance  of  the  initial  sore  ;  they 
pass  through  four  stages — viz.  formation,  softening,  ulceration,  and 
repair. 

3.  Lesions  of  the  Bones. — The  forms  of  bone-disease  comprise  peri- 
ostitis, osteo-periostitis,  and  osteo-myeiitis.  The  characteristics  of  syph- 
ilitic bone-lesions  are  the  following :  they  are  painful ;  the  pain  is  worse 
at  night  and  the  affected  part  is  exquisitely  sensitive  to  touch ;  the  dis- 
ease responds  readily  to  iodid  of  potassium.  The  bones  commonly 
affected  are  the  tibia,  ribs,  sternum,  clavicle,  skull,  and  face-bones.  The 
disease  most  likely  to  be  confounded  with  it  is  tubercular  osteitis. 

Syphilitic  Osteitis.  Tubercular  Osteitis. 

Location. — Common  in  the  bones  of  the  skull.  Seldom  attacks  these  bones. 

History. — History  of  chancre  and  evidences  History  of  tuberculosis,  and  manifestations  in 

of  syphilis  in  other  tissues.  lungs,  glands,  or  other  organs. 

Effects  of  Treatment. — Yields    to   antisyphi-  Affected  by  no  treatment  except  removal  or 

litics.  injection  with  iodoform. 

Course. — Seldom  suppurates.  Generally  ends  in  suppuration. 

4.  Syphilis  in  the  Testicles. — In  the  genitals  of  men  we  frequently 
have  the  chancre,  followed  by  gummatous  deposits  in  the  epididymis 


656 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


and  core  of  one  or  both  testes,  the  distinctly  circumscribed  indurated 
mass  being  readily  recognized  by  palpation.  Syphilitic  epididymitis  is 
to  be  differentiated  from  gonorrheal  epididymitis  by  remembering  that 
syphilis  usually  attacks  the  globus  major,  while  gonorrhea  affects  the 
globus  minor,  and  also  from  the  history  of  a  chancre  in  one  and  dis- 
charge in  the  other.  Sometimes  in  cases  of  urethral  chancre  it  is  hard 
to  get  a  correct  historj^  as  there  would  be  a  discharge  from  both,  which 
might,  however,  be  differentiated  by  the  microscope. 

Tuberculosis  of  the  testicle  usually  follows  involvement  of  the  pros- 
tate, and  tuberculous  subjects  are  rarely  syphilized.  Syphilitic  deposits 
may  sometimes  be  found  in  the  corpora  cavernosa,  urethra,  or  base  of 
of  the  penis,  but  they  are  rare  in  these  localities.  Syphilitic  orchitis  is 
a  not  infrequent  accompaniment  of  late  syphilis,  and,  as  it  comes  on 
insidiously,  is  often  present  without  the  patient's  knowledge. 

In  the  female  syphilitic  gummata  are  sometimes  observed  in  the 
vulva,  and  deposits  or  ulcers  may  be  discovered  in  any  part  of  the 
genital  tract,  but  are  rarely  found  in  the  uterus,  tubes,  or  ovaries. 

The  main  points  of  difference  between  syphilitic  orchitis,  encephaloid 
carcinoma  of  the  testicle,  and  tubercular  orchitis  are  brought  out  in  the 
following  table,  from  An  American  Text-Book  of  Siirgciy  : 


Syphilitic  Orchitis. 
Syphilitic  history. 

Usually  occurs  at  about  twen- 
ty-five or  thirty  years  of 
age. 

Begins  in  the  testicle. 

Is  situated  primarily  in  the 
connective  tissue. 

Tends  to  fibrous  overgrowth. 


Slow  in  its  progress. 
Skin   of   the   scrotum   rarely 
involved. 

Ulceration  or  suppuration 
rare. 

Fistulge  uncommon. 

A  feeling  of  great  weight, 
with  only  such  pain  as  re- 
sults from  dragging  on  the 
cord. 

Tumor  very  hard,  uniform. 

Skin  of  scrotum  purplish,  but 
unaffected. 

Of  moderate  size  ;  rarely  ex- 
ceeds twice  its  normal  di- 
ameter. 

Painless  on  pressure. 

Both  testicles  often  affected. 

Fungus  rare. 


Encephaloid  Carcinoma 
OF  Testicle. 


Tubercular  Orchitis. 


No  history  of  any  special  con-     Tubercular  history. 

dition. 
Any  age.  Not  often  seen  after  thirty. 


Begins    in   the    body   of   the 

organ. 
Begins  by  the  deposit  of  small 

nodules  in  the  seminiferous 

tubules. 
Tends  to  formation  of  patches 

of  softened,    white,   pulta- 

ceous  material. 
Rapid  in  its  course. 
Skin    of   the    scrotum  finally 

involved. 

Ulceration  and  fungus  com- 
mon. 

Fistuls;  common. 

Pain  severe  and  lancinating 
in  advanced  stages. 


Begins  in  the  epididymis. 

Exists  primarily  in  the  tub- 
ules. 

Tends  to  fatty,  caseous,  or 
purulent  degeneration. 

Slow  in  its  progress. 

Skin  involved  only  just  be- 
fore the  formation  of  ab- 
scess. 

Suppuration  common. 

Fistulse  common. 
Little  pain. 


Soft  and  fluctuating.  At  first  hard,  knotty,  irregu- 

lar. 
Network  of  large  veins  over     Skin  congested,  but  otherwise 

surface  of  tumor.  unaffected. 

Attains  great  size.  Of  moderate  size. 


Painless  on  pressure.  Often  painful  on  pressure. 

Generally   only   one    testicle     Often  both  testicles  affected. 

affected. 
Fungus  always  present  in  ad-     Fungus  common. 

vanced  stages. 


THE  DIAGNOSIS  AND    TREATMENT  OF  SYPHILIS.  6^/ 

Syphilitic  Orchitis.  ^'"''^Z'^T^.^.Sr'''"'^         Tubercular  Orchitis. 

No  discharge  or  bleeding.           Bleeds  freely ;   offensive  dis-  Not  so  apt  to  bleed ;  discharge 

charge.  not  so  offensive. 

Lasts  many  years,                          Rarely  extends  beyond  twenty  Lasts  several  years. 

months. 

Curable.                                          Usually  fatal.  Generally  incurable. 

No  involvement   of  inguinal     Inguinal,    iliac,    and    lumbar  Usually  no  inflammation   of 

glands  as  a  rule.                            glands  and  cord  affected.  glands. 

Trcatvicnt. — It  is  better  to  wait  in  all  cases  until  the  appearance  of 
the  secondary  lesions  before  tr>'ing  to  administer  specific  treatment. 
Although  many  excellent  authorities  advise  the  administration  of  mer- 
cury as  soon  as  the  diagnosis  is  fully  established,  at  the  present  day  the 
majority  of  authorities  advise  delay.  Early  treatment  postpones  the 
appearance  of  the  lesions,  but  does  not  modify  their  general  character, 
and  it  is  thought  that  in  some  cases  it  increases  their  severity.  The 
experience  of  the  past  three  or  four  centuries  places  mercury  at  the 
head  of  the  list  of  remedies  on  account  of  its  potency  in  controlling 
and  subduing  the  ravages  of  this  malady.  From  time  to  time  many 
medicines,  mineral  and  vegetable,  have  been  lauded  as  possessing  supe- 
rior efficacy,  yet  none  of  them  have  acquired  the  confidence  of  the 
medical  profession  that  mercury  possesses. 

At  the  beginning  of  treatment  all  hygienic  measures  should  be 
adopted  to  improve  the  general  health  and  condition  of  the  patient. 
The  use  of  tobacco,  both  smoking  and  chewing,  should  be  interdicted, 
as  the  habit  seems  to  invite  the  development  of  lesions  of  the  mucous 
membrane  of  the  mouth  and  throat.  The  teeth  should  receive  careful 
attention,  and  be  placed  in  perfect  condition  by  removing  all  accumula- 
tions of  tartar,  filling  cavities  that  may  exist,  and  smoothing  down  rough 
and  jagged  edges  and  points  that  may  irritate  the  tongue  and  mucous 
membrane  of  the  cheeks. 

All  habits  of  intemperance  and  excess  must  be  abandoned,  and  the 
daily  life  of  the  patient  made  to  correspond  with  the  most  advanced 
rules  contributory  to  health.  Mercury  may  be  introduced  into  the 
system  through  different  channels  and  by  different  methods — by  hypo- 
dermic injections,  by  the  mouth,  by  inunction,  or  by  fumigation. 

Different  preparations  of  the  drug  and  different  modes  of  adminis- 
tration are  advocated  by  individual  authorities.  Whatever  method  is 
observed,  it  should  be  remembered  that  it  is  neither  to  be  administered 
too  lavishly  on  the  one  hand,  nor  too  niggardly  on  the  other,  and 
always  with  careful  observations  as  to  its  effects  upon  the  system  of 
the  patient  and  upon  the  lesions  of  the  disease.  Among  the  prepara- 
tions of  mercury  that  are  employed  are  corrosive  sublimate,  calomel, 
yellow  and  red  oxide,  biniodid,  mercurial  ointment,  oleate,  salicylate, 
and  many  others.  lodid  of  potassium  is  chiefly  applicable  to  the  later 
stages  of  syphilis,  and  is  not  surpassed  by  mercury  in  its  power  and 
efficacy  to  dissipate  and  resolve  gummatous  lesions.  The  iodids  are 
often  extremely  valuable  in  the  treatment  of  syphilis  when  the  patient 
does  not  seem  to  tolerate  the  use  of  mercury.  lodid  of  potassium  is 
more  often  used  by  the  inexperienced  in  the  treatment  of  the  early 
lesions,  but  in  the  hands  of  the  expert  it  is  reserved  for  the  later  trouble. 

42 


658  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

In  its  administration  it  is  well  to  prepare  a  solution  of  i  ounce  of  the 
drug  to  I  ounce  of  water.  The  dosage  must  be  regulated  in  accord- 
ance with  the  severity  of  the  demands  of  the  case  and  the  degree  of 
tolerance  manifested  by  the  patient.  It  is  better  to  commence  its  use 
by  prescribing  from  5  to  8  drops  of  this  solution,  well  diluted,  after 
meals,  gradually  increasing  the  dosage  by  the  addition  of  i  drop  a  day 
until  30,  40,  or  even  60  drops  have  been  reached.  If  serious  symptoms  of 
iodism  ensue,  its  use  must  be  abandoned  or  rather  the  dose  diminished. 
In  urgent  attacks  of  cephalalgia  and  meningitis  and  in  osteo-periostitis 
the  dose  must  often  be  large,  but  abandoned  or  greatly  diminished  as 
soon  as  relief  is  obtained. 

The  iodids  are  capable  of  producing  the  most  satisfactory  results  in 
properly  selected  cases.  They  often  disagree  with  many  patients,  but 
by  careful  administration  of  a  graduated  dose  and  by  keeping  the  diet 
bland  and  unirritating  there  are  but  {<:i\\  cases  that  cannot  be  coaxed 
into  tolerance.  Their  beneficent  effect  will  well  repay  the  patient  and 
gratify  the  surgeon  for  all  the  details  and  painstaking  care  that  have 
been  observed  in  their  exhibition.  They  will  occasionally  produce  the 
symptoms  of  iodism.  The  toxic  effects  of  the  iodids  are  frequently  mani- 
fested by  a  pronounced  metallic  taste  in  the  mouth,  all  the  symptoms 
of  acute  coryza,  eruptions  on  the  skin  resembling  acne  and  urticaria, 
-distention  of  the  abdomen  with  gas,  pain,  and  constipation.  With 
abandonment  of  the  drug  the  toxic  effects  rapidly  disappear.  There 
are,  no  doubt,  rare  and  isolated  cases  that  are  so  peculiarly  susceptible 
to  the  influence  of  iodids  that  their  use  must  be  avoided  and  some 
preparation  of  mercury  substituted. 

Mercury  may  be  introduced  into  the  system  by  either  the  exter- 
nal or  the  internal  micthod.  The  external  method  employs  inunction 
and  fumigation ;  the  internal  method  consists  in  the  administration  of 
the  drug  by  the  mouth  or  its  subcutaneous  injection  with  the  hypo- 
dermic syringe.  The  method  of  internal  use  has  been  modified  by  many 
syphilographers  into  different  systems  styled  "  continuous,"  continuous 
tonic,  and  interrupted.  The  matter  may  be  greatly  simplified  by  ob- 
serving the  following  directions,  which  if  carefully  followed  will  prevent 
the  development  of  any  toxic  effects.  Calomel  is  not  used  very  much 
at  the  present  time  for  internal  administration,  but  is  a  ver>'  excellent 
preparation  to  be  employed  in  fumigation,  etc.  Corrosive  sublimate, 
protoiodid,  and  the  tannate  are  undoubtedly  as  suitable  as  anything  that 
can  be  selected.  The  "  auld  lang  syne  "  doses  are  no  longer  in  vogue. 
The  bichlorid  may  be  given  in  doses  of  ^^  to  |-  gr. ;  protoiodid,  -^  to 
\  gr. ;  tannate,  \  to  i  gr.  As  the  malady  to  be  treated  is  essentially  a 
chronic  disease,  it  is  obvious  that  the  exhibition  of  remedies  must  be 
prolonged ;  therefore  it  is  not  proper  to  see  how  large  a  dose  of  mer- 
cury the  patient  will  tolerate  at  a  given  time,  but  to  carefully  determine 
how  large  a  dose  he  can  take  continuously  and  not  affect  his  general 
health,  and  at  the  same  time  prove  curative.  The  student  should  be 
impressed  with  the  fact  that  he  is  treating  an  individual  and  not  syph- 
ilis alone,  and  that  each  individual  is  a  law  unto  himself  If  the  ad- 
ministration of  mercury  by  the  mouth  seems  to  disagree  with  the  pa- 
tient in  doses  that  are  sufficient  to  control  the  progress  of  the  malady, 
or  if  the  case  develops  stomatitis  or  gastro-enteritis,  it  will  be  neces- 


THE   DIAGNOSIS  AND    TREATMENT  OF  SYPHILIS.  659 

sary  to  resort  to  inunction,  hypodermic  injection  of  mercurials,  or 
fumigation. 

When  the  disease  has  existed  for  several  months,  and  just  presents 
itself  for  treatment,  it  is  better  to  commence  the  use  of  inunction  or 
fumigation  at  once.  Inunction  consists  in  rubbing  into  the  skin  metal- 
lic mercury  or  some  form  of  it  mixed  with  a  fatty  substance.  It  is 
the  oldest  of  all  known  methods,  and  is  very  potent  in  its  results. 
It  relieves  the  alimentary  tract  from  the  frequent  disagreeable  effects 
of  mercury.  The  officinal  blue  ointment  is  a  very  reliable  form ;  the 
dose  to  be  employed  should  correspond  to  the  size,  weight,  and  general 
condition  of  the  patient;  the  patient  should  be  directed  to  properly 
cleanse  the  skin  with  warm  water  and  soap ;  from  i  to  3  scruples  should 
be  rubbed  in  until  it  has  disappeared.  Any  region  of  the  body  may  be 
selected.  Should  a  dermatitis  develop  on  the  surface  to  which  the  in- 
unction has  been  applied,  another  part  may  be  selected.  While  this 
process  is  being  followed  the  diet  should  be  generous  and  nourishing. 
Iron,  quinin,  and  strychnin  may  be  given  with  very  beneficial  effects, 
and  especially  in  those  cases  that  are  prone  to  take  on  the  anemia, 
pallor,  and  weakness  peculiar  to  the  condition  known  as  syphilitic 
cachexia. 

Fumigation  is,  without  doubt,  the  most  speedy  and  efficacious 
method  that  can  be  employed  in  cases  of  emergency.  It  must  be 
used  with  considerable  care.  The  elaborate  apparatus  found  in  bath- 
houses is  by  no  means  necessary.  All  that  is  essential  is  a  spirit 
lamp  ;  directly  over  the  flame  a  metallic  plate  of  tin  or  copper  is  placed, 
holding  upon  its  surface  from  40  to  60  grains  of  calomel  and  cin- 
nabar in  the  proportion  of  20  parts  of  the  former  to  40  of  the  latter ; 
a  kettleful  of  boiling  hot  water  is  placed  by  its  side ;  the  patient  is 
stripped  of  all  clothing  and  placed  upon  a  chair  in  an  improvised  tent 
made  of  a  blanket  or  of  bed-ticking,  which  is  made  to  fit  the  neck 
closely,  leaving  the  head  exposed.  About  half  an  hour  is  usually 
necessary  for  a  bath,  and  it  should  not  be  repeated  oftener  than  every 
second  or  third  day.  The  effect  of  the  bath  in  some  cases  is  to  pro- 
duce great  weakness,  and  a  temporary  resort  to  alcoholic  stimulants 
may  become  necessary  to  avert  a  profound  feeling  of  faintness.  The 
bath  should  never  be  giv^en  immediately  after  eating,  but  preferably 
before  retiring  at  night.  Some  patients  do  not  seem  to  tolerate  the 
baths ;  the  depressing  effect  is  often  caused  by  using  too  much  of  the 
steam  vapor.  From  ten  to  twenty  baths  are  usually  necessar}^  to  pro- 
duce satisfactory  results. 

Hypodermic  injections  of  the  soluble  and  insoluble  salts  of  mercury 
are  recommended  by  some  authorities.  The  advocates  of  this  method 
claim  for  it  rapidity  of  effect :  it  relieves  the  stomach  and  digestive 
tract ;  it  admits  of  more  perfect  accuracy  in  dose  ;  it  can  be  employed 
in  all  stages  of  the  malady ;  it  is  followed  by  but  few  relapses ;  it  is 
very  simple,  cleanly,  and  inexpensive.  The  injections  are  made  every 
second  or  third  day,  and  of  the  following  solution  :  Hydrarg.  chlor.  cor- 
ros.,  gr.  j ;  glycerin,  aqua  dest.,  aa.  oj.  Of  this  inject  10  minims.  The 
toxic  effects  of  the  drug  are  often  speedily  developed,  and  saliv^ation 
may  be  produced  at  the  second  or  third  injection.  Abscesses,  boils, 
nodes,  and  sloughing  of  the  tissues  frequently  follow  this  form  of  treat- 


66o  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

mcnt.  The  strictest  antiseptic  precautions  in  all  details  must  be  ob- 
served in  adopting  this  method. 

Finally,  syphilis  is  a  disease  that  requires  prolonged  treatment.  If 
it  is  treated  as  it  should  be,  the  patient  must  be  under  the  medical 
attendant's  care  for  two  and  a  half  or  three  years.  As  soon  as  a  diag- 
nosis has  been  made  at  the  beginning  of  treatment,  the  patient  should 
be  made  acquainted  with  the  seriousness  of  his  trouble.  It  is  usually 
not  necessary  to  say  much  regarding  the  horrors  of  syphilis :  he 
has  undoubtedly  already  an  exaggerated  opinion  as  to  the  rav- 
ages that  are  alDout  to  overwhelm  him.  No  class  of  cases  requires 
so  much  good  judgment  and  discretion  in  their  treatment  as  the  vene- 
real affections,  and  especially  sj^philis.  While  we  are  warranted  in  en- 
couraging the  patient  with  hope  and  a  satisfactory  prognosis  in  the 
great  majority  of  cases,  we  must  not  forget  to  impress  upon  his  mind 
that  it  not  infrequently  exhibits  a  very  irregular  course,  and  cases  that 
are  apparently  simple  and  mild,  if  neglected  or  abandoned,  may  manifest 
the  severest  features  of  the  disease.  He  should  be  informed  that  he  is 
not  to  marry  for  six  months  after  the  disappearance  of  the  lesions,  and 
only  then  if  he  has  at  the  same  time  been  under  specific  treatment  for 
two  or  three  years. 

Hereditary  Syphilis. — In  the  great  majority  of  cases  the  disease 
is  ifliherited  from  the  mother.  Women  who  have  contracted  syphilis, 
and  while  passing  through  its  early  and  active  stages  have  become  preg- 
nant, are  rarely  able  to  carry  the  products  of  conception  to  full  term ; 
every  pregnancy  results  in  abortion  until  the  disease  wanes  in  its  sever- 
ity. The  virus  loses  its  intensity  and  potency,  and  becomes  so  attenu- 
ated as  to  exert  no  longer  its  influence  upon  the  viability  of  the  fetus.  A 
\Qry  large  percentage  of  the  infants  of  syphilitic  mothers  are  dead,  or 
if  viable  at  birth  die  soon  afterward.  Some  live  on  to  early  childhood, 
a  few  beyond  the  age  of  puberty.  As  a  general  rule,  it  may  be  regarded 
as  a  fatal  disease.  At  birth  an  infant  may  present  the  manifestations 
of  syphilis  and  speedily  succumb  to  its  deadly  influence.  In  other 
cases  the  infarrt  at  birth  may  look  as  plump,  fresh,  and  vigorous  as 
babies  usually  do,  but  between  the  first  and  third  month  it  begins  to 
show  signs  of  failing  health  ;  its  appetite  fails,  it  loses  flesh,  the  skin 
becomes  sallow ;  it  is  restless,  loses  sleep,  and  is  feverish.  Following 
these  symptoms  there  appears  a  rash,  the  syphilitic  roseola ;  it  may  be 
only  a  mild  efflorescence  that  is  mistaken  for  "  red  gum  "  or  "  undue 
heat,"  and  it  may  be  overlooked,  or  may  develop  an  unmistakable  form 
of  eruption,  the  macular  syphilides,  the  lesions  being  bright  and  red 
with  tendency  to  desquamate.  The  color  of  the  eruption  is  often  a  dirty 
brown.  At  this  time  also  coryza  develops  :  the  discharge  is  at  first  of 
a  serous  nature,  but  becomes  purulent  and  bloody ;  it  is  offensive  in  its 
odor,  excoriates  the  lip  and  nostrils,  interferes  with  breathing,  and  con- 
stitutes the  "  snuffles."  The  early  manifestations  of  hereditary  syphilis 
are  usually  confined  to  the  skin,  and  consist  of  the  erythematous,  papu- 
lar, pustular,  and  sometimes  tubercular  forms.  Bullous  lesions  quite 
often  appear,  and  are  described  as  syphilitic  pemphigus ;  they  always 
indicate  a  very  serious  and  grave  condition,  and  rarely  if  ever  improve 
under  treatment.  Papules  of  a  moist  character  are  found  at  the  cor- 
ners of  the  mouth,  upon  the  genitalia  and  anal  region.     Gummatous 


THE  DIAGNOSIS  AND    TREATMENT  OF  SYPHILIS.  66 1 

deposits,  ulcers,  furuncles,  and  abscesses  are  frequent.  Should  the  in- 
fant survive  the  early  stage  and  live  to  attain  childhood,  the  bones  may 
become  involved.  Those  most  frequently  attacked  are  the  tibia,  ulna, 
radius,  femur,  and  bones  of  the  skull.  There  is  in  the  early  months 
often  a  swelling  of  the  phalanges  and  the  metatarsal  and  metacarpal 
bones,  constituting  dactylitis  syphilitica.  Children  who  possess  the 
syphilitic  taint  are  liable  to  attacks  of  interstitial  keratitis,  purulent 
discharges  from  the  ear  persistent  and  intractable.  The  teeth  of  sec- 
ond dentition  present  singular  markings  that  were  first  pointed  out  by 
Mr.  Hutchinson  as  presenting  conclusive  evidence  of  the  disease.  The 
upper  central  incisors  are  the  test  teeth.  When  first  cut  they  are  short, 
narrow,  and  very  thin.  After  a  time  a  crescentic  portion  from  the 
edges  breaks  away,  leaving  a  broad,  shallow  notch.  The  two  teeth 
often  stand  widely  apart,  but  sometimes  converge.  While  he  regards 
the  markings  of  the  teeth  as  of  great  value  in  the  late  manifestations 
of  the  disease,  there  are  other  signs  which  greatly  aid  in  establishing  a 
diagnosis — viz.  sunken  bridge  of  the  nose,  prominent  frontal  eminences, 
scars  at  the  corners  of  the  mouth,  silky  softness  of  the  skin  with  ab- 
sence of  color,  and  a  history  of  past  attacks  of  interstitial  keratitis. 
This  disease  usually  affects  tjoth  eyes  and  causes  very  great  impair- 
ment of  sight,  lasting  over  several  months.  It  then  clears  away,  leav- 
ing the  corneae  a  little  cloudy ;  afterward  there  remains  a  steel-gray 
luster  on  the  iris.  A  peculiar  form  of  phagedenic  ulceration,  some- 
times erroneously  called  lupus,  may  affect  any  part,  but  is  often  seen 
upon  the  nose.  The  disease  shows  itself  in  the  bones  in  the  form  of 
periosteal  nodes.  Mucous  patches,  as  in  acquired  syphilis,  affect  the 
mouth  and  throat ;  the  nails  are  frequently  affected,  and  there  may  be 
alopecia,  both  transient  and  permanent.  Care  must  be  taken  in  the 
diagnosis  of  syphilitic  bone-disease  that  it  is  not  confounded  with 
rickets.  In  rickets  the  shafts  of  the  bones  become  thin  and  are  not 
enlarged  as  in  syphilis  ;  there  are  not  the  characteristic  nodes  ;  the  fon- 
tanelles  are  open  and  are  not  prematurely  closed  by  the  development 
of  osteophytes.    In  rickets  the  bones  are  more  flexible  than  in  syphilis. 

Should  the  patient  surviv^e  the  period  of  infancy,  there  may  be  a 
complete  absence  of  syphilitic  manifestations  until  the  age  of  puberty, 
when  they  suddenly  reappear. 

Hereditary  syphilis  produces  arrest  of  development :  the  patients 
look  younger  than  they  really  are,  and  generally  these  subjects  are 
far  below  the  average  in  physical  and  mental  power.  In  females  there 
is  little  or  no  development  of  the  mammae,  menstruation  is  delayed, 
the  hair  in  the  axilla  and  on  the  mons  veneris  is  very  scanty  ;  the  joints, 
nervous  system,  and  viscera  are  frequently  affected.  To  present  a 
typical  picture  of  a  patient  afflicted  with  hereditary  syphilis  the  words 
of  Cauganeux  are  to  the  point :  "  Had  I  in  a  few  words  to  present  the 
ideal  clinical  type  of  late  hereditary  syphilis,  I  should  select  a  young 
girl  eighteen  or  twenty  years  old,  whose  eyes  should  present  traces  of 
interstitial  keratitis ;  the  teeth  should  be  eroded  and  crescentically 
notched,  at  the  same  time  they  should  be  small  and  irregular;  the 
hearing  should  be  partially  or  totally  lost  in  consequence  of  frequent 
attacks  of  otorrhea ;  the  genitals,  possessing  all  the  attributes  of  vir- 
ginity,  should   be   small,   the   mons   veneris    and  axillae    smooth,   the 


662  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

mammjE  without  prominence,  and  menstruation  scarcely  established. 
Add  to  these  all  the  tertiary  lesions  you  please  and  you  will  have 
before  you  a  complete  picture  of  hereditary  syphilis.  To  the  triology 
of  Hutchinson,  keratitis,  defective  incisors,  otorrhea,  I  propose  to  add 
two  other  signs — general  congenital  atrophy  and  general  arrest  of 
development." 

Treatment  of  Hereditary  Syphilis. — The  treatment  of  hereditary 
syphilis  should  not  begin  /;/  ntero,  as  indicated  by  some  writers.  Only 
when  the  diagnosis  has  been  actually  and  undeniably  established  is  it 
quite  proper  to  administer  specific  treatment  to  the  mother,  and  thus 
modify  the  intensity  of  the  virus  as  it  relates  to  the  fetus.  For  this 
purpose  it  is  better  to  rely  upon  inunction.  When  the  child  is  born 
and  is  known  to  be  affected  inunction  may  also  be  adopted.  The  skin 
of  the  infant  is  very  sensitive,  and  care  must  be  observed  that  dermatitis 
does  not  develop.  The  flannel  binder  that  is  applied  to  the  belly  may 
be  used  for  the  purpose  of  inunction.  From  lo  to  20  grains  of  the 
officinal  mercurial  ointment,  with  one  or  two  scruples  of  vaselin,  may 
be  smeared  upon  the  bandage ;  the  natural  movements  of  the  child 
will  produce  the  necessary  friction.  Baths  may  be  ordered  daily  of 
corrosive  sublimate,  10  grains  to  a  pailful  of  warm  water,  allowing  the 
infant  to  remain  in  the  bath  from  ten  to  fifteen  minutes,  after  which  it 
is  carefully  wiped  and  dried.  Should  there  be  present  in  the  folds  of 
the  neck  or  about  the  genitals  and  anus  moist  papules,  they  may  be 
dusted  with  equal  parts  of  calomel  and  boric  acid.  Especial  care 
should  be  observed  that  the  skin  is  kept  scrupulously  clean. 

Keyes  advises  the  use  of  corrosive  sublimate  internally,  h  grain  to 
6  ounces  of  water ;  of  this  a  teaspoonful  may  be  given  hourly  for  the 
first  day,  the  second  day  every  two  hours,  the  third  day  every  three 
hours,  or  at  longer  intervals  should  it  seem  to  disagree.  Should  the 
babe  maintain  its  weight  and  seem  to  thrive,  the  treatment  may  be  con- 
tinued under  careful  observation  ;  if  it  emaciates  and  grows  pale,  the 
mercurial  treatment  must  be  diminished  or  withheld  for  a  time.  lodid 
of  potassium  should  not  be  administered  to  a  young  infant,  as  it  will 
inevitably  disagree  with  the  function  of  digestion  and  interfere  with 
nutrition.  Later  on,  during  the  manifestations  of  the  disease  in  child- 
hood, it  will  exert  a  beneficent  influence  if  prescribed  in  judicious  doses 
and  with  the  ordinary  care  that  should  always  be  observed  in  the  ad- 
ministration of  this  drug.  Local  lesions  should  receive  the  topical 
applications  that  are  advised  in  the  acquired  form.  The  nutrition  of 
the  infant  or  child  should  be  maintained  by  the  selection  of  proper  food 
that  can  be  easily  digested  and  thoroughly  assimilated.  Infants  will  not 
do  well  when  bottle-fed,  and  the  mother's  breast  is  always  to  be  recom- 
mended in  preference  to  any  other  means  of  nourishment. 


THE   DIAGNOSIS  AND    TREATMENT  OF   TUMORS.  663 


CHAPTER    XIII. 

THE    DIAGNOSIS   AND  TREATMENT   OF   TUMORS. 

It  is  perfectly  natural  for  the  patient  and  surgeon  to  divide  all 
tumors  into  two  great  classes — benign  and  malignant.  The  one  class 
means  simple  inconvenience ;  the  other  means  terrible  and  prolonged 
suffering.  One  implies  hope,  the  other  despair.  A  benign  or  inno- 
cent tumor  has  the  following  characteristics  :  It  does  not  produce  pain 
except  by  pressure ;  it  generally  has  a  capsule  beyond  which  it  does 
not  spread,  and  if  it  is  diffuse  it  never  infiltrates  the  surrounding  tissues  ; 
it  never  spreads  to  the  lymphatic  glands  ;  if  once  removed,  it  never 
returns ;  it  never  endangers  life  except  when  by  its  size  it  presses  upon 
vital  organs. 

A  malignant  tumor  is  very  different.  While  the  benign  or  innocent 
growth  is  attended  with  little  or  no  pain,  the  malignant  tumor,  as  a  rule, 
condemns  its  victim  to  a  life  of  anguish  ;  it  is  not  confined  within  a 
capsule,  but  infiltrates  the  surrounding  tissues ;  it  affects  the  lymphatic 
glands ;  it  disseminates — that  is,  breaks  out  in  distant  organs  ;  it  is 
almost  sure  to  return  after  removal ;  except  in  the  rare  cases  in  which  the 
disease  can  be  totally  removed  by  operation  the  termination  is  death. 
In  the  examination  of  a  given  tumor  the  first  inquiry  will  relate  to 
the  history  of  the  growth.  Is  it  congenital  or  acquired  ?  Is  it  growing, 
receding,  or  stationary?       Is  it   idiopathic  or  the  result  of  an  injury? 

After  obtaining  a  history  the  tumor  may  be  examined  by  inspection 
and  palpation.  The  position  of  the  growth  should  be  noted,  and  the 
structure  to  which  it  is  attached,  as  skin,  fascia,  muscle,  periosteum,  or 
bone.  Is  it  movable  or  fixed  ?  Is  its  outline  sharply  defined,  or  does 
it  gradually  shade  off  into  the  neighboring  parts  ?  What  is  its  con- 
sistence ?  Is  it  either  hard,  soft,  firm,  gelatinous,  or  fluctuating?  Is  it 
smooth  or  lobulated  ?  The  condition  of  the  neighboring  lymphatic 
glands  should  next  receive  attention,  and  any  enlargement  should  be 
carefully  noted. 

Many  tumors  have  already  been  considered  under  the  special  organs  ; 
what  follows  is  a  brief  account  of  the  more  common  growths  and  their 
characteristics.  It  is  often  impossible  to  decide  the  nature  of  a  neoplasm 
before  its  removal ;  all  we  can  undertake  to  say  is  that  the  growth  is  one 
which  should  be  removed  by  operation,  leaving  its  histological  cha- 
racters to  be  afterward  determined  by  the  use  of  the  microscope. 

Connective-tissue  Tumors. — Of  benign  tumors  the  most  com- 
mon are  lipomata,  fibromata,  myxomata,  chondromata,  osteomata, 
gliomata,  neuromata,  angeiomata,  lymphangeiomata,  and  myomata. 

Lipomata,  or  fatty  tumors,  are  found,  as  a  rule,  upon  the  trunk  and 
the  parts  of  the  limbs  nearest  to  the  trunk.  They  are  made  up  of  fat,  and 
are  the  most  common  of  all  neoplasms.  Middle  life  is  the  period  most 
liable,  as  in  most  persons  at  that  time  the  body  shows  a  tendency  to 
the  formation  of  fat.  Fatty  tumors  are  classified  according  to  the  posi- 
tions they  occupy  as  subcutaneous,  subserous,  submucous,  subsynovial, 
intermuscular,  intramuscular,  periosteal,  and  meningeal.  Lipomata  by 
their  weight  frequently  change  their  position.     Fig.   273  represents  a 


664 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


growth  which  began  a  httlc  to  the  right  of  the  umbihcus,  but  grad- 
ually sank  to  the  scrotum,  distending  the  latter  enormously ;  the  mass 
hung  down  to  a  point  midway  between  the  knees  and  ankles.  It  was 
successfully  removed  by  Dr.  Phelps  of  Hawarden,  Iowa,  to  whom  the 
writer  is  indebted  for  a  photograph  of  the  case. 

The  subcutaneous  lipomata  are  easily  recognized  by  their  being 
lobulated,  diffuse,  and  closely  connected  with  the  skin.  When  the 
skin  overlying  the  tumor  is  raised  it  becomes  dimpled,  owing  to  the 
fasciculi  of  connective  tissue  which  pass  between  it  and  the  tumor.    The 

deeper  tumors  are  most  difficult  of 
recognition.  A  fatty  tumor  con- 
nected with  the  periosteum  of  a 
long  bone  closely  resembles  a  sar- 
coma. It  grows  more  slowly,  how- 
ever, and  if  circumscribed  has  few 
of  the  characters  of  sarcoma.  In 
the  groin  it  may  simulate  abscess  or 
hernia.  Abscess  is  preceded  by  a 
history  of  suppuration,  and  hernia 
has  its  characteristic  positions  and 
an  impulse  on  coughing.  In  the  ab- 
dominal cavity  all  we  can  say  is  that 
a  tumor  is  present,  but  its  real  cha- 
racter must  be  determined  after  re- 
moval. 

Treatment. — The  removal  of  fatty 
tumors  is  attended  with  littledifficulty 
or  risk  except  when  the  growth  is  in 
the  abdomen. 

Fibromata,  or  fibrous  tumors, 
are  composed  of  fully-developed 
fibrous  tissue  and  form  dense  cir- 
cumscribed masses,  sometimes  lobu- 
lated, sometimes  uniform  in  outline 
(Fig.  274).  When  connected  with 
mucous  membrane  they  constitute 
a  large  proportion  of  the  polypoid 
growths  usually  met  with.  These 
tumors  occur  wherever  connective 
tissue  is  found,  and  may  therefore  be 
met  with  in  any  part  of  the  body. 
They  are  hard,  freely  movable,  elas- 
tic, and  heavy.  Their  most  common  situations  are  the  uterus,  skin, 
fascia,  capsules  of  the  joints,  the  synovial  fringes,  periosteum,  nose, 
gums,  and  nerves.  The  simple  fibroma  is  composed  of  bundles  of 
wavy  fibrous  tissue ;  the  fibers  are  long  and  fully  developed.  In  the 
growing  points  the  immature  cells  may  be  seen  undergoing  transfor- 
mation into  fibers.  In  fibro-sarcomata  the  cell-elements  predominate, 
and  they  do  not  become  fully  developed  into  perfect  fibers. 

A  peculiar  form  of  fibroma  which  is  met  with  in  the  corium  or 
subcutaneous  tissue  is  known  as  subcutaneous  painful  tubercle.     It  is 


Fig.  273. — Lipoma  commencing  to  the 
right  of  umbilicus  and  gradually  changing 
its  position  by  gravitation  (from  a  photo- 
graph in  the  collection  of  Dr.  Phelps,  Ha- 
warden, Iowa). 


THE  DIAGNOSIS  AND    TREATMENT  OF   TUMORS.  665 

commonly  met  with  in  the  lower  extremities,  and  more  frequently  in 
women  than  in  men.  It  is  sometimes  exceedingly  painful,  but  in  size 
is  seldom  larger  than  a  pea. 

Molluscum  fibrosum  is  a  remarkable  condition  in  which  the  skin 
and  subcutaneous  tissue  become  the  seat  of  enormous  fibrous  growths, 
causing  either  numerous  small  tumors  or  a  diffuse  neoplasm  which 
hangs  in  folds  about  the  body.     Its  cause  is  obscure. 

Chondxomata,  or  cartilage-tumors,  and  osteoraata,  have  been  con- 
sidered in  connection  with  Diseases  of  Bone. 

Myxomata  are  tumors  in  which  mucin  is  the  preponderating  ele- 
ment, and  consist  of  connective  tissue  as  a  framework  in  the  meshes 
of  which  a  fluid  is  contained  that  is  almost  identical  with  Wharton's 
jelly  of  the  umbilical  cord.  These  growths  occur  as  nasal  and  aural, 
rectal,  and  some  forms  of  uterine  polypi,  cutaneous  myxomata,  and 
neuro-myxomata ;  their  appearance  is  so  characteristic  that  diagnosis 
is  not  difficult. 

Myo-fibromata  are  morbid  growths  composed  of   muscular  and 


Fig.  274. — Fibroma  (from  a  photograph  in  the  collection  of  l>r.  Strickler). 

fibrous  tissue  combined.  The  muscle-fibers  are  of  the  unstriped 
variety  and  occur  in  closely  interlacing  bundles.  Many  uterine  tumors 
fall  under  this  class. 

Angeiomata,  or  vascular  tumors,  are  composed  of  arteries,  veins, 
or  capillaries,  or  of  cavernous  spaces  containing  blood. 

Gliomata  are  tumors  having  about  the  same  consistence  as  the 
cortical  substance  of  the  brain,  and  are  found  in  the  central  nervous 
system  only.  They  have  no  characteristic  diagnostic  symptoms  apart 
from  other  brain  or  spinal  tumors. 

Neuromata  are  composed  of  nerve-filaments  or  tissue,  but  the  term 
is  often  applied  to  neoplasms  growing  upon  nerves,  no  matter  what 
their  histological  characters  may  be.  A  common  form  of  neuroma  is 
the  bulb  which  forms  upon  a  divided  nerve  after  amputation,  and  which 
is  often  exceedingly  painful.  It  seems  to  be  produced  by  the  nerve- 
fibers  doubhng  back  upon  themselves  and  forming  a  tortuous  mass. 


666  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

In  the  treatment  care  should  be  taken  to  form  a  flap  of  the  nerve- 
sheath  so  as  to  cover  in  the  divided  end  of  the  nerve  after  cutting  away 
the  tumor. 

Sarcomata  are  composed  of  embryonic  connective  tissue,  the  cell- 
elements  largely  preponderating  over  the  intercellular  substance.  A 
convenient  classification  of  sarcomatous  tumors  is  based  upon  the 
shape  and  disposition  of  the  cells,  and  is  as  follows:  i.  Round-celled 
sarcoma ;  2.  Lymph-sarcoma  (resembling  lymphatic  glands) ;  3.  Spin- 
dle-celled sarcoma ;  4.  Myeloid  sarcoma  (resembling  the  red  marrow 
of  bones);  5.  Alveolar  sarcoma;  6.  Melano-sarcoma. 

Sarcomata  are  found  wherever  there  is  connective  tissue ;  hence  we 
look  for  them  in  connection  with  fascia,  subcutaneous  cellular  tissue, 
periosteum,  intermuscular  septa,  marrow  of  bone,  the  ovary,  the  testi- 
cles, occasionally  in  the  brain,  and  rarely  in  the  spinal  cord  and  nerves. 
They  first  make  their  appearance  as  nodules,  single  or  multiple ;  they 
are  usually  firm,  but  may  be  soft.  They  have  one  remarkable  cha- 
racteristic, and  that  is  the  rapidity  of  their  growth,  and  this  dis- 
tinguishes them  from  all  other  tumors.  They  are  frequently  observed 
after  injuries.  It  is  not  uncommon  to  see  the  disease  occurring  in  a 
strong  young  man  who  several  months  previously  had  received  a  blow 
or  fractured  a  bone.  Cicatrices  are  sometimes  the  seat  of  these  tumors. 
They  are  rarest  in  children,  rare  between  ten  and  twenty  years,  most 
frequent  in  middle  life,  and  rarer,  again,  in  old  age.  Except  when  located 
in  or  on  a  nerve-trunk  sarcomata  are  usually  painless  until  they  begin  to 
ulcerate.  As  a  rule,  the  softer  the  tumor  the  more  rapid  is  its  growth 
and  the  worse  the  prognosis.  Sarcomata,  except  in  their  early  stages, 
have  no  capsule.  They  rapidly  infiltrate  the  fibrous  tissue  with  which 
they  are  connected,  and  give  the  tumor  a  diffuse  character.  In  addi- 
tion to  spreading  by  infiltration,  they  are  liable  at  any  time  to  reproduce 
themselves  in  distant  organs,  especially  the  lung.  They  do  not  spread 
to  neighboring  lymphatic  glands,  and  this  constitutes  one  of  the  main 
differences  between  them  and  carcinomatous  tumors. 

The  treatment  is  complete  extirpation  when  this  is  possible.  If  there 
is  not  a  reasonable  prospect  of  getting  away  the  whole  of  the  diseased 
structure,  it  is  useless  to  operate. 

Bpithelial  Tumors. — In  this  type  of  tumors  epithelium  is  the 
distinguishing  and  essential  feature,  as  connective  tissue  is  in  the 
growths  we  have  been  considering. 

"Warts. — The  simplest  form  of  epithelial  growth  is  the  wart  or 
papilloma.  It  is  an  outgrowth  from  an  epithelial  surface,  and  is  com- 
posed of  an  axis  of  fibrous  tissue  surmounted  by  epithelium  and  con- 
taining blood-vessels.  Warts  are  common  on  the  hands — especially  of 
children,  who  do  not  keep  their  skin  as  clean  as  they  should — the 
anus,  the  glans  penis,  the  labia,  and  other  parts  which  are  subjected  to 
irritating  discharges,  such  as  gonorrhea. 

Villous  papillomata  are  warty  growths  arising  from  mucous  mem- 
brane, and  especially  that  of  the  bladder. 

Intra-cystic  Papillomata. — Warty  growths  are  found  upon  the 
lining  membrane  of  certain  cysts — e.  g.  cysts  of  the  mammary  gland 
and  cysts  of  the  paraoophoron  and  Gartner's  duct,  and  in  cysts  of  the 
thyroid  glands. 


THE  DIAGNOSIS  AND    TREATMENT  OF  TUMORS. 


667 


Psammomata  are  warts  found  only  in  the  pia  mater  of  the  brain 
and  spinal  cord. 

Epithelioma. — As  long  as  the  epithelium  is  limited  by  the  base- 
ment-membrane the  growth  falls  within  the  category  of  warts ;  when 
the  epithelium  passes  beyond  this  and  infiltrates  the  subjacent  con- 
nective tissue,  it  is  an  epithelioma.  The  most  common  situation  of  this 
variety  of  morbid  growths  is  at  the  junction  of  skin  and  mucous  mem- 
brane ;  hence  we  find  them  on  the  lip,  at  the  verge  of  the  anus,  and  on 
the  prepuce.  They  may  also  occur  on  any  part  of  the  skin,  and  are 
more  apt  to  appear  upon  scar-tissue.  The  first  appearance  of  an  epi- 
thelioma is  a  fissure,  a  wart,  or  a  nodule  on  the  cutaneous  or  mucous 
surface. 

The  disease  may  remain  stationary  for  months  or  even  years,  but 
sooner  or  later  ulceration  takes  place  and  may  involve  a  considerable 
area  (Fig.  275).     The  characters  of  the  ulcer  must  be  closely  studied. 


Fig.  275. — Epithelioma  of  the  knee  (from  a  photograph  in  the  collection  of  Dr.  Strickler,  New 

Ulm,  Minn.). 

Its  base  and  margins  are  indurated,  and  may  stand  up  as  a  per- 
pendicular wall ;  the  surrounding  skin  is  not  inflamed ;  the  surface  of 
the  ulcer  is  warty  or  like  a  cauliflower  or  excavated ;  it  has  a  foul,  fetid 
discharge  containing  sloughs  of  tissue.  The  lymphatic  glands  in  the 
neighborhood  sooner  or  later  become  enlarged.  In  some  cases  a 
tumor  of  considerable  size  is  formed.     A  typical  epithelioma,  and  the 


668 


SIRGICAL   DIAGNOSIS  AND    TREATMENT. 


most  common  of  all,  is  that  found  in  the  lower  lip  of  men  (see  Epithe- 
lioma of  the  Lip).  Epithelioma  is  very  rare  under  thirty  years  of 
age,  the  great  majority  of  cases  occurring  between  forty  and  seventy. 

Adenomata. — These  tumors  are  composed  of  gland-tissue,  but  dif- 
fer from  normal  gland-structure  by  their  failure  to  produce  the  secre- 
tion peculiar  to  the  gland  which  they  resemble.  The  ovary,  mamma, 
and  thyroid  are  the  glands  most  commonly  affected.  In  the  intestine 
a  small  adenoma  may  cause  intussusception.  They  are  not  encapsuled, 
do  not  invade  the  surrounding  tissues,  do  not  affect  the  neighboring 
lymphatic  glands,  nor  produce  secondary  deposits.  They  occur  in 
young  persons,  and  are  always  found  in  connection  with  a  secreting 
gland.  Upon  these  characteristics  we  must  rely  to  differentiate  ade- 
nomata from  other  tumors.  They  are  not  dangerous  to  life,  and  usually 
call  for  removal  on  account  of  the  pressure-symptoms  to  which  they 
gi\'e  rise. 

Carcinomata,  or  cancers,  are  tumors  of  pronounced  malignancy 
(Fig.   276).     They  have   no    capsules,  but  infiltrate  the   neighboring 


Fig.  276. — Medullary  cancer :  recurrence  six  months  after  removal  of  the  eye  (from  a  photo- 
graph in  the  collection  of  Dr.  Lincoln). 

tissues,  and  at  a  comparatively  early  period  spread  to  neighboring 
lymphatic  glands.  Every  part  of  the  body  which  has  secreting 
glands  is  liable  to  carcinoma.  The  most  common  situations  are  the 
mammae,  the  glands  of  the  cervix  utero,  the  prostate.  It  is  rare  before 
the  age  of  twenty-five,  increasing  in  frequency  with  each  decade  there- 
after. 

Although  the  division  of  cancer  into  scirrhus,  encephaloid,  and  col- 


DISEASES  AND   INJURIES   OF  THE  NECK. 


669 


loid  is  not  a  good  classification  from  a  pathological  standpoint,  it  is 
convenient   clinically. 

The  differential  diagnosis  between  encephaloid,  scirrhus,  and  sar- 
coma is  thus  summarized  by  Gross : 


Encephaloid. 

The  tumor  is  soft  and  elastic, 
but  not  uniformly. 

It  grows  rapidly,  and  soon 
acquires  a  large  bulk,  per- 
haps ultimately  attaining  the 
volume  of  an  adult's  head. 


The  pain  is  slight  and  eiTatic 
until  ulceration  begins, 
when  it  becomes  more 
severe  and  fixed. 

There  is  always  marked  en- 
largement of  the  subcutane- 
ous veins. 

The  ulcer  is  foul  and  fungous, 
with  thin,  undermined,  and 
livid  edges,  and  is  subject 
to  frequent  and  copious 
hemorrhage. 

There  is  generally  early  lym- 
phatic   involvement. 


Occurs  at  all  periods  of  life. 


Is  most  frequent  in  the  eye, 
testicle,  mamma,  lymphatic 
glands,  bones,  skin,  and 
cellular  tissue. 


The  disease  usually  terminates 
fatally  in  from  nine  to  twelve 
months. 


Scirrhus. 

Uniformly  hard  and  inelastic, 
feeling  like  a  marble  be- 
neath the  skin. 

Growth  is  slow  and  bulk  com- 
paratively small,  the  tumor 
rarely,  even  in  the  worst 
cases,  exceeding  the  vol- 
ume of  a  large  fist. 


The  pain  begins  early,  is  dis- 
tinctly localized,  and  is  of  a 
sharp,  darting,  burning,  or 
lancinating  character. 

In  scirrhus  these  vessels  re- 
tain their  natural  size  or 
are  only  slightly  enlarged. 

The  ulcer  is  encrusted  with 
spoiled  lymph,  and  has 
steep,  abrupt  edges,  look- 
ing as  if  it  had  been  scooped 
out  of  the  part ;  bleeding 
little  and  seldom. 

Usually  not  until  late,  or 
shortly  before  ulceration 
occurs. 


Seldom    before    the 
forty-five. 


ige 


of 


Never  occurs  in  the  eye  and 
testicle,  and  rarely  in  the 
bones,  skin,  and  lymphatic 
glands. 


Seldom  sooner  than  eighteen 
months  or  two  years. 


Sarcoma. 

May  be  firm,  tense,  and  elas- 
tic ;  generally  uniformly  soft 
and  apparently  fluctuating. 

May  remain  stationary  or 
nearly  so  for  many  years; 
awakened  into  activity,  it 
progresses  more  rapidly 
than  encephaloid,  and  may 
attain  an  enormous  volume 
in  a  short  time. 

No  pain  until  ulceration  sets 
in,  and  even  then  usually 
insignificant. 

The  subcutaneous  veins  only 
slightly,  if  at  all,  enlarged. 

Tendency  to  ulcerate  slight 
and  late  in  the  disease,  the 
sore  being  superficial  and 
not  subject  to  hemorrhage. 


Singularly  free  from  lymph- 
atic involvement,  or,  if  the 
glands  are  affected  at  all, 
they  become  so  quite  late. 

Generally  before  forty,  and 
most  commonly  between 
that  age  and  twenty. 

Always  begins  in  the  connec- 
tive tissues,  particularly  sar- 
coma of  the  extremities; 
most  common  in  skin,  peri- 
osteum, and  bone  ;  infre- 
quent in  lymphatic  and  se- 
creting glandular  organs. 

No  reliable  data ;  patients, 
however,  often  survive 
many  years,  even  after 
repeated    extirpation. 


CHAPTER   XIV. 


DISEASES   AND   INJURIES   OF  THE   NECK. 

Congenital  Malformations. — These,  though  not  very  common, 
are  seen  from  time  to  time,  and  include  cysts  and  fistula;  due  to  imper- 
fect development  of  the  branchial  clefts. 

Branchial  cysts  may  be  situated  at  the  base  of  the  tongue,  con- 
stituting one  kind  of  ranula. 

Branchial  cysts  in  the  neck  may  be  divided  into  four  groups : 
{(I)  dermoid  cysts,  {b)  cystic  hygroma,  (<:)  simple  cyst  or  hydrocele  of 
the  neck,  and  [d)  malignant  cyst. 


6/0  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

The  dermoid  cysts  are  usually  smaller  and  firmer,  and  are  to  be 
distinguished  from  the  other  varieties  by  the  absence  of  fluctuation. 

Cystic  hygroma  is  a  collection  of  cysts  in  a  bed  of  fibrous  tissue. 
This  cystic  tumor  often  attains  a  large  size  and  has  a  very  irregular 
outline.     The  irregular  surface  is  the  main  diagnostic  feature. 

Simple  cysts  also  often  attain  a  large  size.  They  have  a  smooth 
surface,  and  if  tense  feel  almost  solid ;  otherwise  fluctuation  ma)'  be 
elicited. 

Malig-nant  cysts  are  extremely  difficult  to  diagnose,  and  are  gen- 
erally mistaken  for  abscesses ;  e\-en  after  operation  the  diagnosis  is 
often  doubtful.  The  manner  in  which  the  wound  breaks  down  and  the 
rapid  infiltration  of  surrounding  tissues  soon  render  painfull}'  evident 
what  the  surgeon  has  to  deal  with. 

Treatment. — Dermoid  c}'sts  should  be  removed  in  toto,  and,  as  a 
rule,  this  can  be  done  without  difficulty.  The  complete  removal  of 
simple  cysts  or  cystic  hygromata  is  usually  a  somewhat  serious  under- 
taking on  account  of  their  thin  walls  and  intimate  relation  to  surround- 
ing structures.  Incision  and  drainage  are  preferable.  Operations  on 
malignant  cysts  are  usually  hopeless,  as  they  almost  constantly  recur. 
However,  their  removal  has  sometimes  to  be  undertaken  for  relief  of 
pain,  and  is  exceedingly  difficult  on  account  of  the  manner  in  which 
they  surround  and  infiltrate  the  sheaths  of  the  vessels  and  nerves. 

Branchial  fistulse  are  situated  along  the  edges  of  the  sterno- 
mastoid  muscles  and  may  communicate  with  the  pharynx.  Their 
situation  serves  to  distinguish  them  from  tracheal  fistula;,  which  are 
situated  mesially. 

Treatment^  when  desirable,  must  be  directed  to  exciting  granulation 
and  consequent  adhesion  at  the  distal  extremity  of  the  fistula,  avoiding 
mere  occlusion  of  the  external  orifice. 

Cellulitis  of  the  neck  may  prove  a  most  serious  condition, 
depending  on  its  position  with  regard  to  the  layers  of  fascia,  and  also 
on  the  extent  to  which  it  spreads.  For  instance,  if  deep  enough  it 
may  produce  dangerous  dyspnea  by  pressure  on  the  trachea,  or  it  may 
produce  dangerous  pressure  on  the  other  important  structures  in  the 
neck,  or  it  may  extend  to  the  mediastinum  or  axilla.  A  special  form 
of  cellulitis  of  the  neck  is  the  submaxillar}-  form,  better  known  as 
Ludwig's  angina.  In  this  condition  the  swelling  around  the  submax- 
illary gland  encroaches  so  much  on  the  floor  of  the  mouth  that  there  is 
great  difficulty  in  swallowing  or  breathing.  As  in  other  forms  of  an- 
gina, there  is  great  depression.  The  disease  often  proves  fatal,  some- 
times gradually,  sometimes  from  edema  of  the  glottis,  suddenly. 

Ti'catnicnt. — Incision  is  of  course  the  correct  procedure  in  every 
case,  and  even  when  there  is  so  much  induration  that  the  diagnosis  is 
not  absolutely  certain,  one  will  err  on  the  safe  side  in  making  a  diag- 
nostic opening.  The  incision  should  not  be  deep,  and  should  be  per- 
formed after  the  method  of  Hilton ;  that  is,  make  a  small  opening  and 
burrow  in  the  cellular  tissue  w'ith  a  pair  of  closed  forceps,  and  when 
pus  is  found  exuding  alongside  the  blades,  the}^  can  be  opened  to  allow 
admission  of  the  exploring  finger.  After  evacuation  of  the  pus  a 
counter-opening  may  be  made  if  necessar}'  to  establish  drainage. 

Abscesses  of  the  neck  may  arise   in  connection  with    carious 


DISEASES  AND  INJURIES   OF   THE   NECK.  67 1 

teeth,  as  a  periadenitis  in  connection  with  scrofulous  glands  or  in  con- 
nection with  necrosis  of  the  lower  jaw  or  cartilage  of  the  larynx. 

These  abscesses  are  to  be  treated  on  general  principles. 

Cicatrices  the  result  of  burns,  producing  one  form  of  wry-neck,  are 
to  be  treated  as  cicatrices  elsewhere. 

Injuries   of  the    Neck. 

Contusions  of  the  neck  may  cause  spasm  of  the  glottis,  which 
may  result  in  death  unless  tracheotomy  be  performed,  or  there  may  be 
fracture  of  the  hyoid  bone  or  cartilage  of  the  larynx,  and  subsequent 
subcutaneous  emphysema  or  injuries  to  the  floor  of  the  mouth,  with 
difficult  respiration  and  deglutition. 

The  treatment  consists  in  keeping  the  parts  at  rest  as  far  as  possible 
by  forbidding  the  patient  to  talk  and  by  the  use  of  the  nasal  tubes. 
Evaporating  lotions  may  also  be  applied  to  the  neck. 

Wounds  of  the  Neck. — Cut-throat  may  serve  as  an  example  of 
wounds  of  the  neck.  Unless  the  individual  is  left-handed  the  cut  will 
be  found  to  extend  obliquely  from  above  downward  and  from  left  to 
right  across  the  middle  line.  The  wound  may  extend  into  any  part 
of  the  larynx  or  trachea,  and  even  to  the  esophagus,  without  injuring 
the  carotids,  which  lie  somewhat  deeply  and  are  protected  by  the 
sterno-mastoid  muscles. 

The  dangers  resulting  from  cut-throat  are  hemorrhage,  entrance  of 
air  into  veins,  septic  pneumonia,  and  septicemia. 

Treatment. — In  every  case  the  patient  must  be  carefully  watched 
during  treatment,  lest  he  renew  his  attempts  at  self-destruction.  All 
hemorrhage  must  be  carefully  arrested,  and  if  there  appears  to  be 
dyspnea,  it  will  be  well  to  ensure  safety  by  the  introduction  of  a  trache- 
otomy-tube. Divided  structures  should  be  sutured  where  necessary. 
If  the  patient  is  much  collapsed  from  hemorrhage,  transfusion  of  nor- 
mal saline  solution  will  be  indicated.  If  the  skin-wound  be  allowed  to 
close  before  the  tracheal  wound,  we  will  have  emphysema  of  the  neck. 
The  remedy  is  obvious  :  keep  the  skin-wound  open  till  the  trachea  has 
been  closed  by  nature  or  by  art. 

Tumors   of    the   Neck. 

Tumors  of  the  neck,  if  they  reach  any  considerable  size,  are  apt  to 
produce  serious  symptoms  from  pressure  on  the  many  important  struc- 
tures in  the  region,  and  if  malignant  the  danger  is  increased  immensely, 
for  the  difficulty  of  removing  them  without  injury  to  the  structures  is 
great,  and  in  many  cases  cannot  be  overcome. 

Glandular  Tumors. — These  are  by  far  the  most  common  of  all 
tumors  of  the  neck.  They  may  be  divided  into  {a)  syphilitic,  {b)  tuber- 
cular, and  (c)  malignant  gland-disease. 

Syphilitic  enlarg-ement  of  the  glands  of  the  neck,  especially  of  the 
glandulae  concatenat^e  under  the  posterior  edge  of  the  sterno-mastoid 
muscles,  is  very  common  in  secondary  syphilis,  and  one  of  its  most 
distinctive  features.  Glands  thus  affected  seldom  or  never  suppurate, 
and  may  be  treated  by  mercury  given  internally  or  by  inunction. 

Tubercular    glands   are  very   common,   and    have    usually  as    an 


672 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


exciting  cause  irritation  cxtendini^  from  some  other  part ;  for  example, 
from  a  carious  tooth  or  from  eczema  of  the  scalp.  At  first  they  are 
firm  and  hard,  freely  movable,  and  can  easily  be  shelled  out,  but  later 
periadenitis  develops,  and  their  removal  is  rendered  more  difficult,  or 
they  may  caseate  or  suppurate  and  give  rise  to  an  abscess. 

The  treatment  is  removal,  and  this  is  one  of  the  most  common  and 
often  most  difficult  operations  in  surgery,  frequently  involving  a  tedious 
dissection  and  exposure  of  the  carotid  sheath.  The  complexity  and  num- 
ber of  the  veins  in  this  region  also  add  considerably  to  the  difficulty 
and  danger.  Even  though  a  divided  vein  be  ligatured,  embolism  following 
detachment  of  a  thrombus  is  a  danger  which  must  not  be  overlooked. 

When  the  glands  have  become  adherent  it  is  well  to  scrape  the 
capsule  in  addition.     Abscesses  should  be  opened  and  scraped. 

The  malignant  glandular  enlargement  may  be  primary,  as  in 
Hodgkin's  disease  and  some  rare  cases  of  carcinoma,  but  it  is 
generally  secondary  to  some  primary  deposit  about  the  lips,  tongue, 
pharynx,  esophagus,  or  mammae. 

Hodgkin's  disease,   or  malignant  lymphoma,  is  a  progressive 


Fig.  277. — Hodgkin's  disease  (from  a  patient  of  Dr.  J.  E.  Moore). 

enlargement  of  glands  accompanied  by  anemia.  Its  surgical  interest 
depends  mainly  on  the  difficulty  of  diagnosis  in  the  early  stages  of  the 
disease  from  tubercular  gland  disease,  and  also  to  a  certain  extent  from 
syphilitic  enlargements.  From  syphilis  the  diagnosis  must  be  made  by 
a  careful  inquiry  as  to  the  presence  of  other  secondary  symptoms  or 


DISEASES  AND   INJURIES    OF   THE   NECK.  673 

the  former  existence  of  a  chancre.  The  differentiation  from  tubercular 
glands  is  more  difficult,  but  the  following  points  may  be  of  service : 
Tuberculosis  of  the  glands  most  frequently  affects  the  submaxillary 
group,  while  in  this  disease  the  glands  along  the  sterno-mastoid  mus- 
cles are  more  frequently  affected  (Fig.  277).  The  age  of  the  patient 
is  important,  Hodgkin's  disease  being  more  common  in  young  adults. 
The  extension  of  the  disease  to  glands  in  other  parts  of  the  body  and 
the  progressive  anemia  will  settle  the  point  ultimately.  Again,  tuber- 
cular glands  tend  to  suppurate.  This  is  not  observed  in  malignant 
lymphona.  Tubercular  glands,  owing  to  periadenitis,  coalesce  into 
masses,  while  in  Hodgkin's  disease  the  glands  remain  separate  from 
one  another.  Possibly  a  microscopic  examination  for  tubercle  bacilli 
may  be  a  valuable  aid  to  diagnosis  at  an  early  stage. 

Treatment. — Surgical  interference,  except  for  relief  of  pressure- 
symptoms,  is,  as  a  rule,  useless.  Some  glands  might  be  excised  at  an 
early  stage  to  admit  of  examination  microscopically.  Arsenic,  phos- 
phorus, and  other  drugs  have  been  employed  by  physicians  in  the 
treatment  of  this  disease  without  satisfactory  results. 

Actinomycosis  and  leprosy  may  also  affect  the  glands  of  the  neck, 
but  do  not  call  for  special  attention  in  this  section. 

Other  tumors  of  the  neck  are  lipomata,  simple  sebaceous  cysts, 
and  cysts  in  connection  with  the  bursa  above  the  thyroid  cartilage,  but 
they  do  not  call  for  any  comment  apart  from  that  made  in  the  intro- 
duction to  this  subject. 

The  treatment  is  the  sa^me  as  for  the  condition  occurring  in  other 
parts  of  the  body. 

Diseases  of  the  Parotid  Gland. 

Parotiditis,  or  mumps,  is  an  acute  infective  inflammation  of  the 
parotid  gland,  and  is  attended  by  the  usual  febrile  symptoms,  with  the 
local  addition  of  pain  in  swallowing.  The  disease  sometimes  assumes 
the  proportions  of  an  epidemic,  and  whole  families  and  even  schools 
may  be  laid  up.  In  a  small  percentage  of  cases  a  curious  complication 
of  orchitis  in  boys  and  mastitis  or  ov^aritis  in  girls  arises.  The  inflamma- 
tion usually  resolves  spontaneously,  but  in  a  few  cases  suppuration 
ensues. 

Treatnient. — In  a  non-suppurative  case  relief  of  pain  is  the  chief 
objective,  and  this  may  be  attained  to  a  considerable  extent  by  hot  or 
other  anodyne  applications,  as  lead  and  opium.  Where  suppuration 
has  occurred  the  abscess  must  be  opened,  and  here  care  must  be  taken 
to  avoid  injuring  the  facial  nerve  or  Steno's  duct  by  making  the  incision 
parallel  to  these  structures. 

Tumors  of  the  parotid  include  adenoma,  chondroma,  or  fibro- 
chondroma  also  sarcoma  and  carcinoma.  The  diagnosis  between 
simple  and  malignant  tumors  is  often  extremely  difficult,  and  must 
depend  on  the  usual  questions  of  age,  rapidity  of  growth,  and  glandular 
infection. 

Treatment. — When  the  tumor  is  simple  and  placed  superficially 
removal  may  be  comparatively  easy,  care  being  taken  to  avoid  injury 
to  the  facial  nerve  and  Steno's  duct  by  making  the  incision  parallel  to 
4:5 


6/4  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

these  structures.  When  the  tumor  is  mahgnant  or  extends  deeply  the 
dissection  becomes  much  more  difficult  and  dangerous,  and  involves 
serious  risk  to  the  external  carotid  arter>^,  which  passes  through  the 
gland,  and  also  to  the  internal  carotid  artery  and  internal  jugular  vein, 
which  lie  in  contact  with  its  deep  surface. 

Diseases  of  the  Thyroid  Gland. 

The  thyroid  gland  has  had  much  attention  directed  to  it  of  late 
on  account  of  the  discovery  that  myxedema,  a  disease  depending 
on  atrophy  of  the  gland,  can  be  cured  by  the  administration  of  thy- 
roid glands  procured  from  some  of  the  lower  animals,  especially  the 
sheep.  Myxedema  comes  under  the  consideration  of  the  physician 
rather  than  the  surgeon,  but  an  artificial  variety  known  as  cachexia 
strumapriva  may  be  observed  after  complete  removal  of  the  gland. 

Goiter,  or  Bronchocele. — The  thyroid  gland  occasionally  under- 
goes enlargement,  known  as  goiter  or  bronchocele.  Goiter  forms  a 
soft  pulsatile  swelling  of  uniform  size.  On  auscultation  over  the 
tumor  a  blowing  murmur  can  be  frequently  heard,  due  to  the  increased 
vascularity  of  the  gland.  It  may  cause  danger  to  life  by  pressure  on 
the  trachea,  and  the  compression  is  generally  lateral,  causing  the  lumen 
•of  the  tube  to  become  triangular.  Occasionally  from  sudden  congestion 
of  a  goiter  the  dyspnea  may  become  urgent. 

Several  varieties  may  be  distinguished  : 

1.  Goiter  depending  on  increased  growth  of  tissues  already  existing 
in  the  gland  and  called  parenchymatous,  fibrous,  or  cystic  according  to 
the  preponderating  tissue. 

2.  Malignant  goiter,  depending  on  a  malignant  new  growth  in  the 
gland,  either  carcinomatous  or  sarcomatous. 

3.  Exophthalmic  goiter,  where  the  goiter  is  complicated  by  exoph- 
thalmos or  protrusion  of  the  eyes  and  attended  with  rapidity  of  the 
heart's  action.  This  disease  is  also  medical  rather  than  surgical, 
although  operative  measures  have  been  occasionally  resorted  to  in  the 
hope  of  obtaining  relief. 

Diagnosis. — Goiter  may  be  easily  distinguished  by  observing  the 
intimate  relation  of  the  swelling  to  the  trachea,  and  also  by  noting  the 
fact  that  the  tumor  moves  up  and  down  on  deglutition.  Malignant 
goiter  will  be  distinguished  by  the  rapidity  of  growth  and  the  speedy 
involvement  of  neighboring  lymphatic  glands. 

Treatment. — The  general  condition  of  the  patient  should  be  attended 
to,  and  for  this  purpose  iron  and  other  tonics  are  indicated.  Local 
applications  may  be  tried,  such  as  iodin  or  the  iodid  of  mercury,  which 
has  so  great  a  reputation  in  India.  To  obtain  the  best  results  from  the 
use  of  iodin  it  is  necessary  to  inject  the  tincture  into  the  tumor. 

Cysts  should  be  incised  and  stuffed  with  gauze,  and  where  the 
dyspnea  is  becoming  great  the  isthmus  should  be  divided,  and  this 
sometimes  results  in  cure  of  the  goiter.  Total  extirpation  should  be  a 
last  resort,  as  the  dangers  of  the  operation  are  considerable  from  hemor- 
rhage and  interference  with  the  recurrent  laryngeal  nerve,  and  there  is 
the  risk  of  cachexia  strumapriva  resulting.  This  latter  condition,  how- 
ever, may  be  overcome  by  the  internal  administration  of  thyroid  extract. 


IXJURIES  AND  DISEASES   OF   THE   BREAST.  6y$ 

When  there  is  sudden  increase  of  the  bulk  of  the  goiter,  causing 
urgent  dyspnea,  ice  should  be  applied,  and,  if  this  is  ineffectual,  there 
must  be  no  delay  in  the  performance  of  tracheotomy. 


CHAPTER    XV. 

INJURIES   AND    DISEASES   OF   THE   BREAST. 

Many  changes  in  the  condition  of  the  breast  are  of  a  physiological 
rather  than  of  a  pathological  character.  The  breast  of  an  infant  a  few 
days  after  birth  may  become  engorged,  swollen,  and  tender.  These 
conditions  soon  subside,  but  under  improper  management  inflammation, 
suppuration,  and  abscess  may  result.  At  puberty,  just  before  or  just 
after  the  first  menstruation,  the  breasts  of  females  show  a  rapid  devel- 
opment, increasing  in  size  and  presenting  an  areola  around  the  nipple. 
Should  the  enlargement  be  confined  to  one  side,  it  may  to  a  careless 
observer  simulate  a  tumor.  The  most  critical  time  in  the  history  of  the 
gland  is  when  it  assumes  its  highest  function — viz.  during  pregnancy 
and  lactation.  During  pregnancy  the  acini  increase  in  size,  forming 
rounded  nodules,  and  these  may  be  the  starting-points  of  benign  but  not 
of  cancerous  tumors.  After  delivery  the  breast  becomes  engorged  in 
a  marked  degree,  and  if  at  this  period  there  should  be  a  breach  of  sur- 
face on  the  nipple  by  which  pyogenic  germs  can  gain  an  entrance,  sup- 
puration and  abscess  are  almost  sure  to  follow.  Another  critical  period 
for  the  breast  is  the  menopause.  The  acini  now  become  atrophied,  and 
during  this  period  of  involution  carcinoma  may  begin. 

Thus  there  are  three  critical  periods  in  the  life  of  the  mammary 
gland,  and  each  has  its  special  danger.  During  pregnancy  a  benign 
tumor  may  begin  to  develop  ;  at  the  beginning  of  lactation  suppuration 
and  abscess  may  occur ;  at  the  menopause  cancer  may  attack  the  gland. 

^Examination  of  the  Breast. — The  patient  should  be  seated  or 
should  recline  upon  a  couch,  in  a  good  light.  The  nipple  is  first  exam- 
ined. It  varies  greatly  in  shape,  and  may  be  prominent,  flattened,  or 
retracted.  A  retracted  nipple  is  a  characteristic  of  cancer  of  the  breast, 
but  it  must  be  associated  with  other  symptoms  of  cancer  to  be  of  any 
value.  According  to  Gross,  it  is  present  in  a  little  over  50  per  cent,  of 
the  cases. 

Other  changes  in  its  shape  are  unimportant.  Cracks  or  fissures  are 
significant,  especially  after  delivery,  as  they  may  prove  to  be  portals  of 
infection  for  pyogenic  germs. 

A  discharge  from  the  nipple  is  observed  under  certain  circumstances. 
In  infants  of  either  sex  such  a  discharge  is  perfectly  harmless  and 
should  be  let  alone.  When  suppuration  takes  place,  it  is  usually  due 
to  meddlesome  manipulation  of  the  nurse,  who  thereby  causes  irrita- 
tion of  the  gland  and  infects  the  nipple  with  germs  from  the  hand. 
During  menstruation  a  discharge  from  the  nipple  is  sometimes  seen. 
A  blood-stained  serum  is  suspicious  of  cancer,  and  is  sometimes  one 


^■j6  SURGICAL   DIAGNOSIS  AXD    TREATMENT. 

of  the  earliest  symptoms.     The  diseases  to  be  sought  for  in  the  nipple 
are — 

1.  Eczema. — This  may  be  a  simple  skin-disease,  running  a  course 
similar  to  eczema  in  any  other  part  and  yielding  to  the  ordinary  rem- 
edies ;  but  there  is  always  a  risk  of  the  disease  running  into  that  which 
is  known  as  Paget's  disease. 

2.  Pagcfs  Disease. — This  disease  is  a  chronic  destructive  inflamma- 
tion of  the  papillary  layer  of  the  nipple  and  the  areola  surrounding  it. 
It  is  found  in  women  between  forty  and  sixty  years  of  age.  At  first 
the  so-called  eczema  is  dry  and  the  epithelium  is  shed  like  scales  of 
bran ;  later  it  has  a  watery  discharge  of  a  yellowish  color  and  sticky. 
The  surface  of  the  nipple  or  areola  becomes  raw,  red,  and  irritable,  and 
this  condition  may  spread  until  within  its  circumference  is  embraced  a 
good  part  of  the  skin  of  the  chest.  It  is  attended  with  a  tingling,  burn- 
ing pain.  Although  Paget's  disease  is  not  a  form  of  epithelioma,  it  no 
doubt  paves  the  way  for  that  disease  by  its  constant  and  long-continued 
irritation.  It  usually  heals  under  soothing  applications.  If  it  does  not, 
it  should  be  excised.  A  chronic  ulcer  with  thickened  edges,  an  irregu- 
lar hardened  base,  and  a  foul-smelling,  ichorous  discharge  is  almost  sure 
to  be  epithelioma.  Enlargement  of  the  glands  in  the  axilla;  would  be 
corroborative  evidence. 

Diseases  of  the  Mammary  Gland. — Inflammation  of  the 
Breast ;  Mastitis  or  Mammitis. — This  is  nearly  ah\a)'s  met  with  in 
nursing  women  about  the  first  or  second  week  after  delivery.  The 
septic  infection  is  in  nearly  every  case  due  to  the  existence  of  chapped 
nipples.  The  early  symptoms  are  a  stiffness  and  uneasiness  of  the 
breast  followed  by  a  chill  and  a  rise  of  pulse  and  temperature.  The 
breast  becomes  hard,  hot,  painful,  and  swollen.  The  inflammation  may 
end  in  resolution  or  go  on  to  suppuration  and  the  formation  of  an  ab- 
scess. If  suppuration  takes  place,  the  breast  continues  painful  and 
throbbing,  the  induration  and  swelling  increase,  and  after  a  few  days 
fluctuation  can  be  felt.  There  are  three  different  positions  in  which 
the  pus  may  collect :  {a)  in  front  of  the  gland,  {f)  in  the  substance 
or  betw^een  the  lobules  (interlobular),  (<r)  behind  the  gland  (post- 
mammary).  The  first  of  these  is  superficial  and  "  points  "  promptly ; 
the  second  is  deeper,  and  fluctuation  may  be  wanting  even  after  other 
symptoms  show  that  an  abscess  has  formed.  The  third  form  is  still 
more  obscure,  but  there  is  pain  when  the  breast  is  pushed  back  against 
the  chest-wall ;  there  is  swelling  at  the  axillary  border  of  the  gland, 
and  this  border  is  rendered  tense  and  prominent  when  the  gland  is 
pushed  back ;  the  axillary  glands  are  enlarged,  and  there  is  pain  when 
the  pectoral  muscles  are  brought  into  action. 

Treatment. — Everything  possible  should  be  done  to  diminish  con- 
gestion in  the  breast.  The  milk  should  be  drawn  off  at  frequent  inter- 
vals by  means  of  a  breast-pump,  the  bowels  kept  relaxed  by  saline 
aperients,  and  the  breast  fomented  with  a  large  moist  gauze  dressing 
saturated  with  boric-acid  solution  and  covered  with  oiled  silk.  This  is 
better  than  the  old  linseed  poultices  employed  by  our  grandmothers, 
and  which  fulfilled  three  conditions — heat,  moisture,  and  filth.  As  soon 
as  it  is  evident  that  pus  is  going  to  form,  a  free  incision  should  be  made 
at  the  point  where  inflammation  appears  to  be  most  intense.   The  incision 


INJURIES  AXD  DISEASES   OF   THE   BREAST.  6y'7 

or  incisions  should  radiate  from  the  nipple,  so  as  to  av^oid  cutting  the 
milk-ducts  transversel}\  The  usual  precautions  against  sepsis  should 
be  taken,  and  local  anesthesia  secured  by  the  injection  of  cocain.  The 
weight  of  the  inflamed  part  adds  greatly  to  the  discomfort,  but  this  can 
be  overcome  by  supporting  the  breast  in  a  sling.  Sometimes  abscesses 
form  in  several  places,  either  at  the  same  time  or  consecutively,  and  tax 
to  the  utmost  the  patience  of  the  physician  and  the  sufferer. 

Chronic  mastitis  is  of  great  interest  to  us  on  account  of  the  close 
similarity  it  sometimes  bears  to  cancer.  The  inflammation  occurs  in 
one  or  more  of  the  lobules ;  the  acini  disappear  or  are  converted  into 
retention-cysts ;  in  the  spaces  between  the  acini  small  round-cells  are 
proliferated,  which  become  organized  into  dense  cicatricial  tissue.  By 
degrees  the  affected  lobules  become  hard,  irregular  in  shape,  and  ad- 
herent to  the  surrounding  tissues.  The  nipple  may  even  be  retracted, 
so  that  when  we  add  the  severe  pain,  ^ve  have  many  of  the  features 
which  make  up  the  picture  of  cancer.  In  many  cases  the  patient 
is  afflicted  about  the  time  of  the  menopause  just  as  in  scirrhus,  and 
when  she  seeks  advice  it  is  because  she  fears  the  disease  is  cancer. 

The  diagnosis  must  rest  upon  the  following  points  :  The  swelling  is 
hard,  but  it  is  not  the  stony  hardness  of  scirrhus  ;  the  surface  is  nodu- 
lar from  the  presence  of  retention-cysts  which  are  soft,  and  not  hard 
like  cancerous  nodules ;  both  breasts  may  contain  one  or  more  lobules 
which  are  simultaneously  affected ;  the  size  of  the  breast  may  increase 
at  each  menstrual  period,  and  the  disease  may  continue  stationary  for 
so  long  a  time  as  to  preclude  the  possibility  of  cancer.  If,  in  spite  of 
all  the  evidence  that  can  be  gathered,  there  is  still  a  reasonable  doubt, 
the  duty  of  the  surgeon  is  to  advise  an  exploratory  incision.  Prepara- 
tions should  be  made  for  a  microscopical  examination  of  the  tissue 
while  the  patient  is  under  the  anesthetic,  and  if  the  disease  prove  to  be 
cancer,  the  radical  operation  should  be  carried  out  forthwith. 

The  treatment  of  chronic  mastitis  is  not  satisfactory.  Tonics  are 
required,  and  the  best  of  these  is  iron.  lodid  of  potassium,  with  liquor 
potassae  in  small  doses  well  diluted,  has  been  recommended  by  Paget. 
The  breast  should  be  well  protected  against  irritation,  and  this  can  be 
effectually  done  by  a  belladonna  plaster,  as  suggested  by  Moullin. 

Neuroses  of  the  Breast. — A  very  large  proportion  of  patients 
who  consult  the  surgeon  for  diseases  of  the  breast  labor  under  a  hor- 
rible dread  of  cancer.  Some  have  tumors,  and  some  have  not.  Of  the 
latter  class,  many  suffer  from  a  form  of  neuralgia.  It  is  common 
among  young  married  women,  and  is  often  associated  with  ovarian 
disease.  The  pain  is  of  a  sharp,  severe,  lancinating  character,  extend- 
ing to  the  axilla  and  running  down  the  arm.  The  gland  and  the  skin 
over  it  are  extremely  hyperesthetic,  great  tenderness  being  complained 
of  even  to  the  slightest  touch.  No  tumor  can  be  felt.  This  is  enough 
to  settle  the  diagnosis,  as  cancer  never  produces  the  hyperesthesia  that 
these  people  complain  of  and  there  is  always  a  tumor. 

Ti'catment. — Driving  the  idea  of  carcinoma  out  of  the  patient's  mind 
is  a  great  step  toward  her  recovery,  and,  once  the  diagnosis  has  been 
arrived  at,  the  surgeon  should  not  consent  to  make  further  examination 
of  the  breast.  Any  ovarian  or  uterine  disease,  if  present,  should 
receive    its    appropriate    treatment :    the    best    hygienic    surroundings, 


678  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

change  of  air  and  tonics,  and  healthful  occupation  of  body  and  mind 
are  indispensable. 

Tumors  of  the  Breast. — The  examiner  should  be  familiar  with 
the  normal  condition  of  the  mammary  glands,  so  that  he  may  not 
imagine  he  has  found  a  tumor  when  the  healthy  gland  is  grasped  be- 
tween his  finger  and  thumb.  Let  the  patient  be  seated,  stand  behind 
her,  and  with  your  nngers  flat  upon  the  breast  press  the  gland  against 
the  ribs.  If  there  is  no  tumor,  you  will  find  only  the  normal  thickness 
of  the  gland  between  your  fingers  and  the  chest-wall.  Now  grasp  the 
gland  between  the  finger  and  thumb  and  examine  its  density,  and 
search  for  nodules  or  other  irregularities  in  its  contour.  If  there  is 
found  a  greater  sense  of  resistance  than  normal,  and  the  patient  is  not 
suckling,  it  may  be  set  down  as  chronic  induration  of  the  mamma.  If, 
in  addition,  there  are  hyperesthesia  and  neuralgic  pain,  as  described  in 
the  preceding  paragraph,  the  patient  has  a  neurosis  of  the  breast.  If 
you  find  a  tumor,  grasp  it  with  one  hand  and  the  gland  with  the  other, 
and  ascertain  whether  or  not  the  one  moves  independently  of  the  other. 
Is  it  situated  toward  the  center  or  the  periphery  of  the  breast  ?  Is  it 
smooth,  nodular,  or  lobulated  ?  Arc  the  edges  sharply  defined  or 
rounded,  or  do  they  shade  off  into  the  surrounding  tissues  ?  Is  it  hard, 
soft,  elastic,  or  fluctuating  ?  Is  there  ulceration,  and  if  so  what  is  the 
nature  of  the  discharge  ?  A  bloody  or  thin  serous  discharge  is  cha- 
racteristic of  cancer.  A  mucous  discharge  is  suggestive  of  glandular 
cysts.  Milk  is  a  physiological  secretion  during  lactation,  and  if  found 
in  connection  with  a  tumor,  that  tumor  is  probably  glandular. 

Next  examine  the  axillae  in  quest  of  enlarged  lymphatic  glands,  the 
outposts  of  the  enemy.  Note  whether  they  are  matted  together  or 
hard  and  ulcerated.  Pass  up  to  the  parts  above  the  clavicle  and  con- 
tinue the  search. 

No  matter  what  classification  of  tumors  may  be  adopted  by  the 
pathologists,  the  clinician,  and  even  the  patient,  naturally  divides  all 
morbid  growths  into  two  classes — the  benign  and  malignant.  The 
space  between  them  is  broad  and  the  limits  well  defined.  The  one 
means  recovery  and  the  other  death. 

The  benign  tumors  of  the  breast  are  cysts,  adenomata,  fibromata, 
myxomata,  lipomata,  and  chrondromata. 

Cysts  are  recognized  by  their  glandular  shape,  their  painlessness, 
slow  growth,  and  fluctuation. 

Adenoma  is  a  rare  form  of  tumor  occurring  usually  in  women 
between  twenty-five  and  forty  who  have  had  many  children.  The 
structure  of  the  tumor  is  essentially  that  of  the  gland.  It  is  recog- 
nized by  its  slow  growth,  by  its  resemblance  to  the  normal  condition 
of  the  gland  in  the  pregnant  woman.  There  are  retraction  of  the 
nipple  and  no  involvement  of  the  axillary  glands.  The  treatment  is 
excision. 

Adeno-flbroma. — This  is  the  most  frequently  met  with  of  all  the 
benign  tumors  of  the  breast.  Clinically,  it  is  impossible  to  distinguish 
it  from  the  preceding  variety.  The  microscope  can  only  settle  the 
question.  The  tumor  is  hard  in  proportion  to  the  amount  of  fibrous 
tissue  it  contains.  It  is  circumscribed  and  elastic,  freely  movable 
beneath  the  skin,  and  when  small  may  be  taken  for  a  cyst.     It  is  lobu- 


INJURJES  AND  DISEASES   OF  THE  BREAST.  679 

lated  and  its  growth  is  slow.  The  patients  are  for  the  most  part  young 
and  unmarried. 

Adeno-sarconia. — In  this  variety  a  more  embryonal  form  of  con- 
nective tissue  enters  into  the  composition  of  the  tumor,  and  it  ap- 
proaches the  malignant  type.  Its  growth  is  rapid,  but  the  axillary 
glands  are  not  involved.  The  tumor  is  heavy,  freely  movable,  slightly 
nodulated,  and  elastic.  It  is  distinguished  from  carcinoma  by  its  being 
less  hard,  by  the  absence  of  glandular  involvement,  and  by  its  free 
mobility. 

Treatment. — Free  removal  of  the  tumor.  In  operating  for  the 
removal  of  tumors  which  show  no  signs  of  malignancy  it  is  important 
to  avoid  an  unseemly  scar.  This  can  be  done  by  turning  up  the  breast 
and  making  the  incision  on  its  lower  surface,  so  that  when  the  wound 
is  healed  the  scar  is  covered  by  the  breast. 

Malignant  Tumors  of  the  Breast. — Sarcoma. — Every  variety 
of  sarcoma  is  found  in  the  breast,  round-celled,  spindle-celled,  and 
giant-celled,  as  well  as  every  form  of  degeneration  which  affects  these 
growths.  The  spindle-celled  sarcoma  is,  however,  by  far  the  most 
common.  It  begins  as  a  single  tumor,  and  at  first  appears  as  innocent 
as  an  adeno-fibroma,  from  w^hich  it  is  almost  impossible  to  distinguish 
it.  As  time  advances  the  true  nature  of  the  tumor  becomes  apparent, 
for  it  starts  up  and  grows  with  frightful  rapidity.  The  growth  is  round 
or  oval,  soft,  and  lobulated.  In  the  cystic  variety  it  is  firm  in  some 
places,  soft  and  elastic  in  others.  After  a  time  ulceration  takes  place  : 
a  large  fungating  mass  is  formed  which  bleeds  on  the  slightest  touch, 
and  all  the  while  the  glands,  except  in  rare  cases,  remain  perfectly 
healthy. 

The  diagnosis  of  sarcoma  in  its  early  stage  is  by  no  means  easy ;  it 
is  plain  enough  when  it  arrives  at  the  stage  of  ulceration.  Then  we 
have  a  large  fungating  mass  of  the  most  malignant  character,  painful 
and  growing  rapidly.  We  know  it  is  not  cancer,  for  the  glands  are 
not  involved  ;  we  therefore  conclude  it  must  be  sarcoma.  At  this  later 
period  the  hope  of  cure  is  very  slight.  To  be  of  any  value  to  the 
patient  the  diagnosis  should  be  made  early,  so  that  the  growth  may 
be  removed  before  it  assumes  malignant  appearances.  The  safest  course 
is  to  remove  any  tumor  that  has  the  characters  of  either  an  adeno- 
fibroma,  an  adeno-sarcoma,  or  a  pure  sarcoma. 

Treatment. — The  tumor  should  be  removed  as  early  as  possible. 
When  it  recurs,  as  it  is  almost  sure  to  do,  it  should  be  removed  again 
and  again,  in  the  hope  that  at  last  it  may  cease  to  recur.  The  dissec- 
tion should  always  be  well  outside  the  capsule,  so  that  none  of  the 
growth  be  left. 

Carcinoma. — Two  elements  play  an  important  part  in  the  forma- 
tion of  cancerous  tumors — viz.  connective  tissue  and  epithelial  cells. 
The  tumor  is  hard  or  soft  according  to  the  preponderance  of  either  of 
these.  If  connective  tissue  is  in  excess,  the  growth  is  hard ;  if  epi- 
thelial cells  displace  connective  tissue,  the  tumor  is  soft.  In  this 
way  we  find  all  grades  of  consistency,  from  the  scirrhus  of  stony 
hardness  at  one  end  of  the  line  to  the  soft  or  medullary  cancer  at  the 
other. 

About  80  per  cent,  of  all  mammary  tumors  are  carcinomata.     The 


68o 


SURGICAL    DIAGNOSIS  AND    TREATMENT. 


remaining  20  per  cent,  are  adeno-fibromala  and  other  forms  of  adenoid 
growths,  sarcomata,  and  cysts. 

Scirrhus,  or  Hard  Carcinoma. — The  patient  herself  is  usually  the 
first  to  notice  that  a  new  growth  is  taking  place  in  her  breast,  and  she 
consults  the  surgeon  to  dispel  or  confirm  her  fears. 

In  examining  such  a  patient  begin  with  the  history.  Carcinoma 
attacks  women  at  or  after  the  climacteric.  There  is  often  a  history 
of  injuiy  to  the  breast,  as  a  blow  or  a  fall.  The  irritation  pro- 
duced by  Paget's  disease  is  a  fruitful  source  of  cancer  Passing  the 
fingers  over  the  breast  in  the  manner  already  described,  a  tumor  is 
felt  which  is  of  stony  hardness,  and,  if  found  at  an  early  stage,  is  a 
mere  nodule,  ill  defined,  and  it  cannot  be  separated  from  the  lobules 
around  it.     The  most  common  situation  is  the  outer  and  upper  quad- 


FlG.  278. — Advanced  carcinoma  of  the  breast  (from  a  photograph  in  the  collection  of 

Dr.  T.  S.  Roberts). 

rant  of  the  gland — that  is  to  say,  the  nearest  point  to  the  axilla.  The 
mode  in  which  this  tumor  grows  is  of  the  greatest  importance.  It  has 
been  compared  to  a  crab  turned  upon  its  back  and  grasping  everything 
within  its  reach ;  hence  the  name  cancer.  It  grows  by  infiltrating  the 
surrounding  tissues.  Having  studied  the  hardness  and  mode  of  growth, 
four  cardinal  symptoms  should  now  be  looked  for : 

1.  Contraction  of  the  tumor.  This  causes  a  drawing  in  of  the  milk- 
ducts,  and  produces  the  retracted  nipple,  which  is  a  very  important  sign. 
It  also  produces  a  drawing  in  of  the  skin  at  points  here  and  there  all 
over  the  tumor — the  so-called  "  pig-skin." 

2.  Are  the  glands  affected  ?  The  axillary  glands  are  not  far  off,  and 
at  an  early  stage  the  disease  spreads  to  them.  They  are  of  a  stony 
hardness,  like  the  tumor  itself 

3.  Pain.     This  is  generally  a  very  prominent  symptom,  and  from 


INJURIES  AND   DISEASES   OF   THE   BREAST.  68 1 

time  immemorial  has  been  described  as  sharp,  stabbing,  or  lancinating. 
It  begins  when  the  tumor  has  reached  some  size,  and  either  catches  in 
its  clutches  the  filaments  of  the  intercostal  nerves  or  presses  upon 
them.  At  first  it  is  more  likely  to  be  felt  at  night,  but  later  it  is 
unceasing.  In  exceptional  cases  there  is  absence  of  pain  throughout 
the  greater  part  of  the  course  of  the  disease,  and  this  fact  should  not  be 
lost  sight  of  in  making  a  diagnosis. 

4.  The  cancerous  cachexia.  When  the  disease  begins  the  patient  is 
otherwise  in  robust  health,  as  a  rule.  In  the  course  of  time,  pain, 
worry,  loss  of  sleep,  and  the  horrible  dread  which  attends  cancerous 
disease  tell  upon  the  constitution  and  show  their  effects  in  the  patient's 
countenance,  giving  it  a  peculiar  pinched  expression  and  drawing  down 
the  corners  of  the  mouth.  Further  evidences  of  cancer  are — [a)  A 
discharge  from  the  nipple  associated  with  a  solid  tumor.  The  dis- 
charge is  usually  of  a  serous  character  mixed  with  blood.  According 
to  Gross,  this  is  peculiar  to  cancer,  {p)  Ulceration.  In  the  course  of 
time  the  pressure  of  the  tumor  upon  the  skin  causes  the  latter  to  slough, 
leaving  an  unhealthy  fungating  mass  with  a  foul-smelling  discharge 
(Fig.  278).  (r)  Nodular  growths  in  the  skin.  Sometimes  there  is  an 
eruption  of  firm  nodules  in  the  skin  of  the  breast  and  chest ;  these 
nodules  run  together  and  form  a  tough,  inelastic  pachyderm. 

Soft  or  Medullary  Cancer. — This  form  of  carcinoma  occurs  in 
about  5  per  cent,  of  all  cases  of  cancer  of  the  breast.  Its  symptoms  are 
the  same  as  those  of  scirrhus,  except  that  the  tumor  is  soft,  less  globu- 
lar in  outline,  its  growth  is  more  rapid,  ulceration  occurs  at  an  earlier 
period  and  causes  a  fungous  protrusion  which  readily  bleeds.  The 
glands  also  are  affected  earlier  in  the  disease. 

The  progress  of  carcinoma,  if  unrelieved  by  operation,  is  from  bad 
to  worse :  ulceration,  sloughing,  pain  by  day  and  by  night,  swelling  of 
the  arm  due  to  pressure  of  the  affected  glands  upon  the  axillary  vein, — 
all  these  wear  and  waste  the  patient  till  she  dies  of  exhaustion,  or 
a  spread  of  the  disease  to  a  more  vital  organ  brings  death  more 
quickly. 

Treatment. — One  method  of  treatment,  and  only  one,  merits  con- 
sideration, and  that  is  complete  removal  at  the  earliest  possible 
moment.  Formerly  it  was  deemed  sufficient  to  remove  the  breast  and 
the  tumor,  keeping  well  into  the  surrounding  tissues,  so  as  to  leave 
none  of  the  cancerous  growth.  This  operation  is  not  now  considered 
sufficient.  The  whole  breast,  the  tumor,  the  glands  of  the  axilla,  and, 
if  necessary,  those  of  the  neighboring  part  of  the  neck  as  well,  must 
be  thoroughly  taken  away. 

The  operation  should  only  be  undertaken  when  it  is  possible  to 
remove  the  whole  of  the  disease.  It  is  therefore  contraindicated  under 
the  following  circumstances  : 

1.  When  the  disease  exists  in  one  or  more  of  the  internal  organs,  as 
the  lungs  or  liver.  These  organs  should  be  carefully  examined  in 
every  case. 

2.  When  the  axillary  and  cervical  glands  are  so  extensively  involved 
as  to  preclude  the  possibility  of  removing  all  the  diseased  tissue. 

3.  When  the  skin  is  studded  with  nodules,  not  only  over  the  breast, 
but  a  considerable  part  of  the  chest. 


682  SURGICAL    DIAGNOSIS  AXD    TREATMENT. 

4.  In  cancer  en  cnirassc,  a  form  in  wliich  the  disease  occurs  mosdy 
in  the  skin  and  forms  a  cuirass-Hke  casing  for  the  chest. 

Although  the  modern  operations  are  more  radical  and  extensive 
than  those  formerly  resorted  to,  the  mortality  has  been  steadily  de- 
creasing. It  was  formerly  17.35  per  cent.,  and,  according  to  Williams, 
the  rate  has  been  reduced  to  9.4  per  cent.  Of  464  cases  reported  by 
Bull,  Dennis,  Weir,  Halsted,  and  Keen,  the  mortality  was  only  0.86  per 
cent.  The  mortality  in  this  country  does  not  certainly  exceed  5  per 
cent.,  and  the  average  of  permanent  cures  is  20.87  per  cent.^ 

Operation. — Of  all  the  procedures  that  have  ever  been  adopted  for 
the  removal  of  carcinoma  of  the  breast,  the  most  radical  and  thorough 
is  that  of  Professor  Halsted.  The  essential  features  in  this  operation 
are  removal  of  the  pectoralis  major  muscle  entirely,  or  all  except  the 
clavicular  portion,  as  the  operator  is  enabled  thereby  to  remove  in  one 


Fig.  279. — Halsted's  operation  for  removal  of  breast:  incision. 

piece  all  of  the  suspected  tissues.  The  reasons  for  removing  suspected 
tissues  in  one  piece  are — (i)  lest  the  wound  become  infected  by  the 
division  of  tissues  invaded  by  the  disease  or  of  lymphatic  vessels  con- 
taining cancer-cells,  and  (2)  because  shreds  or  pieces  of  cancerous 
tissue  might  readily  be  overlooked  in  a  piecemeal  extirpation. 

Of  50  cases  operated  upon  by  this  method,  only  3  showed  local 
recurrence.  The  operation,  as  described  by  Professor  Halsted,  is  as 
follows  : 

"(i)  The  skin-incision  is  carried  at  once  and  everywhere  through 
the  fat. 

"  (2)  The  triangular  flap  of  skin  {a,  b,  c,  Fig.  279)  is  reflected  back 
to  its  base-line,  C  A.  There  is  nothing  but  skin  in  this  flap.  The  fat 
which  lined  it  is  dissected  back  to  the  lower  edge  of  the  pectoralis 
major  muscle,  where  it  is  continuous  with  the  fat  of  the  axilla. 

"  (3)  The   loose  tissue   under   the  clavicular  portion  (the   portion 

'  A/ncrican  Text-Book  of  Surgery. 


INJURIES  AND   DISEASES    OF   THE   BREAST.  683 

usually  left  behind)  of  the  pectoralis  major  is  carefully  dissected  from 
this  muscle  as  the  latter  is  drawn  upward  by  a  broad,  sharp  retractor. 
This  tissue  is  rich  in  lymphatics,  and  is  sometimes  infiltrated  with  can- 
cer— an  important  fact. 

"  (6)  The  splitting  of  the  muscle  is  continued  out  to  the  humerus, 
and  the  part  of  the  muscle  to  be  removed  is  now  cut  through  close  to 
its  humeral  attachment. 

"  (7)  The  whole  mass,  skin,  breast,  areolar  tissue,  and  fat,  circum- 
scribed by  the  original  skin-incision,  is  raised  up  with  some  force,  to 
put  the  submuscular  fascia  on  the  stretch  as  it  is  stripped  from  the 
thorax  close  to  the  ribs  and  pectoralis  minor  muscle.  It  is  well  to 
include  the  delicate  sheath  of  the  minor  muscle  when  this  is  practicable. 

"  (8)  The  lower  outer  border  of  the  minor  muscle  having  been 
passed  and  clearly  exposed,  this  muscle  is  divided  at  right  angles  to 
its  fibers  and  at  a  point   a  little  below  its  middle. 

"  (9)  The  tissue,  more  or  less  rich  in  lymphatics   and  often  cancer- 


/""  \ 

, .  _■-'' 

■  ""^^i 

..-'■"^''' 

V  -    ^ 

/ 

■     --^^ 

J 

f 

ijHB 

Fig.  280. — Halsted's  operation  for  removal  of  breast :  extirpation. 

ous,  over  the  minor  muscle,  near  its  coracoid  insertion,  is  divided  as  far 
out  as  possible,  and  then  reflected  inward  in  order  to  liberate  or  pre- 
pare for  the  reflection  upward  of  this  part  of  the  minor  muscle. 

"(10)  The  upper,  outer  portion  of  the  minor  muscle  is  drawn  up- 
ward (Fig.  280)  with  a  broad,  sharp  retractor.  This  liberates  the  re- 
tractor, which  until  now  has  been  holding  back  the  clavicular  portion 
of  the  pectoralis  major  muscle. 

"(11)  The  small  blood-vessels  (chiefly  veins)  under  the  minor  mus- 
cle, near  its  insertion,  must  be  separated  from  the  muscle  with  the 
greatest  care.  They  are  imbedded  in  loose  connective  tissue,  which 
seems  to  be  rich  in  lymphatics  and  contains  more  or  less  fat.  This  fat 
is  often  infiltrated  with  cancer.  These  blood-vessels  should  be  dissected 
out  very  clean  and  immediately  ligated  close  to  the  axillaiy  vein.     The 


684  SURGICAL   DIAGXOSIS  AND    TREATMENT. 

lit^Mtion  of  these  very  delicate  vessels  should  not  be  postponed,  for  the 
clamps  occludint:^  them  might  of  their  own  weight  drop  off  or  accident- 
alh'  be  pulled  off,  or  the  vessels  themseh'cs  might  be  torn  away  b}'  the 
clamps. 

"  Furthermore,  the  clamps,  so  many  of  them,  if  left  on  the  veins, 
would  be  in  the  way  of  the  operator. 

"(12)  Having  exposed  the  subclavian  vein  at  the  highest  possible 
subclavicular  point,  the  contents  of  the  axilla  are  dissected  away  with 
scrupulous  care,  also  with  the  sharpest  possible  knife.  The  glands  and 
fat  should  not  be  pulled  out  with  the  fingers,  as  advised,  I  am  very 
sorry  to  say,  in  modern  text-books,  and  as  practised  very  often  by 
operators.  The  axillary  vein  should  be  stripped  absolutely  clean.  Not 
a  particle  of  extraneous  tissue  should  be  included  in  the  ligatures  which 
are  applied  to  the  branches,  sometimes  very  minute,  of  the  axillary 
vessels. 

"  In  liberating  the  vein  from  the  tissues  to  be  removed,  it  is  best  to 
push  the  vein  away  from  the  tissues,  rather  than,  holding  the  vein,  to 
push  the  tissues  away  from  it.  It  may  not  always  be  necessar)^  to  ex- 
pose the  artery,  but  I  think  it  is  well  to  do  this  ;  for  sometimes,  not 
usually,  the  tissue  above  the  large  vessel  is  infiltrated,  and  we  should 
not  trust  our  eyes  and  fingers  to  decide  this  point.  It  is  best  to  err  on 
the  safe  side,  and  to  remove  in  all  cases  the  loose  tissues  abo\'e  the 
vessels  and  about  the  axillary  plexus  of  nerves. 

"  (13)  Having  cleaned  the  vessels,  we  may  proceed  more  rapidly  to 
strip  the  axillary  contents  from  the  inner  wall  of  the  axilla,  the  lateral 
wall  of  the  thorax.  We  must  grasp  the  mass  to  be  removed  firmly 
with  the  left  hand,  and  pull  it  outward  and  slightly  upward  with  sufifi- 
cient  force  to  put  on  the  stretch  the  delicate  fascia  which  still  binds  it 
to  the  chest.  This  fascia  is  cut  away  close  to  the  ribs  and  serratus 
magnus   muscle. 

"  (14)  When  we  have  reached  the  junction  of  the  posterior  and  lat- 
eral walls  of  the  axilla,  or  a  little  sooner,  an  assistant  takes  hold  of  the 
triangular  flap  of  skin  and  draws  it  outward,  to  assist  in  spreading  out 
the  tissues  which  lie  on  the  subscapularis,  teres  major,  and  latissimus 
dorsi  muscles.  The  operator,  having  taken  a  different  hold  of  the 
tumor,  cleans  from  within  outward  the  posterior  wall  of  the  axilla. 
Proceeding  in  this  way,  we  make  easy  and  bloodless  a  part  of  the  ope- 
ration which  used  to  be  troublesome  and  bloody.  The  subscapular 
vessels  become  nicely  exposed  and  caught  before  they  are  divided. 
The  subscapular  nerves  may  or  may  not  be  removed  at  the  discretion 
of  the  operator.  Kiister  lays  great  stress  upon  the  importance  of  these 
nerves  for  the  subsequent  usefulness  of  the  arm.  We  have  not  as  yet 
decided  this  point  to  our  entire  satisfaction,  but  I  think  that  they  may 
often  be  spared  to  the  patient  with  safety. 

"(15)  Having  passed  these  nerves,  the  operator  has  only  to  turn 
the  mass  back  in  its  normal  position  and  to  sever  its  connection  with 
the  body  of  the  patient  by  a  stroke  of  the  knife  from  b  to  r,  repeating 
the  first  cut  through  the  skin. 

"All  that  has  been  removed  is  in  one  piece.  There  are  no  small 
pieces  or  shreds  of  tissue.  I  believe  that  we  should  nev^er  cut  through 
cancerous  tissues  when  operating  if  it  is  possible  to  avoid  doing  so. 


DISEASES  AND   INJURIES   OF  FEMALE    GENERATIVE    ORGANS.     685 

The  wound  might  become  infected,  either  by  the  knife  which  has 
passed  through  diseased  tissue,  and  perhaps  carries  everywhere  the 
cancer-producing  agents,  or  by  the  simple  hberation  of  the  cancer-cells 
from  their  alveoli  or  from  the  lymphatic  vessels. 

"  The  operation  as  we  perform  it  is  literally  an  almost  bloodless  one. 
From  the  first  to  the  last  each  bleeding  point  is  stopped  with  an  artery- 
forceps  as  quickly  as  possible.  When  practicable  the  vessels  are 
clamped  before  they  are  divided.  If  no  -blood  is  lost,  there  is  no 
perceptible  shock  from  the  operation.  This  is  true  of  almost  every 
operation.  The  symptoms  which  are  so  often  ascribed  to  shock  are 
due  almost  invariably  to  loss  of  blood.  I  have  performed  this  opera- 
tion for  breast-cancer  on  patients  whose  pulse  before  the  operation 
was  so  feeble  that  the  anesthetizer  and  bystanders  have  pronounced  it 
barely  perceptible.  As  a  rule,  the  pulse  is  little,  if  any,  feebler  after  the 
operation  than  it  was  before  it. 

"The  edges  of  the  wound  are  approximated  by  a  buried  pursestring 
suture  of  strong  silk.  Of  the  triangular  flap  of  skin  {a  b  c)  only  the  base 
is  included  in  this  suture.  The  rest  of  this  flap  is  used  as  a  lining  for 
the  fornix  of  the  axilla.  The  apex  of  this  flap  is  consequently  shifted 
to  a  new  and  lower  position. 

"  The  axilla  is  never  drained,  and  invariably  heals  by  first  intention. 
The  uncovered  wound  often  heals  by  the  so-called  organization  of  the 
blood-clot."  ' 


CHAPTER    XVI. 


DISEASES  AND    INJURIES   OF    THE    FEHALE   GENERATIVE 

ORGANS. 

I.  METHODS  OF  EXAMINATION. 

When  the  patient  presents  herself  for  examination,  she  should  be 
permitted  to  tell  in  her  own  way  all  she  has  to  say  concerning  her 
illness  :  by  this  means  the  examiner  may  not  only  gain  much  valuable 
information,  but  what  is  said  and  the  manner  in  which  it  is  said  will 
give  an  insight  into  the  character  and  disposition  of  the  individual 
which  will  have  great  influence  on  the  subsequent  treatment.  Should 
the  patient  become  too  voluble  in  recounting  her  ailments,  a  ther- 
mometer placed  under  her  tongue  will  check  the  flow  of  language 
and  afford  the  surgeon  a  brief  respite. 

As  diseases  of  the  female  genital  organs  present  many  features 
peculiar  to  themselves,  I  would  recommend  the  following  schedule 
as  more  suitable  than  that  laid  down  for  ordinary  surgical  cases  : 

I. — Family  History. — Parents,  brothers,  sisters,  and  near  rela- 
tions ;  number  dead  and  ages  at  death  ;  state  of  health  of  living  mem- 
bers of  the  famil\'. 

II. — Personal  History. —  i.  Age. 

'  Annals  of  Surgery,  Nov.,  1 894. 


686  SURGICAL    DIAGNOSIS  AXD    rREATMENT. 

2.  Marriage-. — Number  of  children  ;  age  of  first  child ;  condition 
of  health  of  the  children ;  number  of  children  living ;  number  of 
children  dead  ;  causes  of  deaths ;  number  of  abortions  and  mis- 
carriages ;  character  of  previous  labors — prolonged,  difficult ;  instru- 
mental interference ;  character  of  puerperium. 

III. — Previous  Illnesses. —  i.  General  Diseases. 

2.  Disorders  of  Menstniation. — First  appearance  of  menstruation  ; 
when  irregularities  began  ;  .character  of  past  menstrual  i)eriods  ;  pain  ; 
amount  of  discharge ;  duration. 

3.  LeiikorrJiea. — Date  of  its  first  appearance;  amount;  color;  blood; 
number  of  napkins  used  daily ;  whether  more  severe  before  or  after 
menstruation. 

4.  Pain. — When  it  began,  intensity,  location,  duration,  recurrence, 
character ;  increased  by  motion,  sitting,  lying,  standing ;  continuous, 
paroxysmal ;  exacerbations  ;  before,  during,  following,  or  between  men- 
strual periods  ;  feeling  of  weight ;  bearing-down  ;  pressure  in  pelvis  ; 
radiation  to  back,  pubis,  thighs,  rectum,  or  umbilicus. 

IV. — Present  Illness. — (i)  When  it  began;  causes;  continuous; 
intermittent.  (2)  Menstruation,  leiikorrhea,  and  pain,  as  given  under 
previous  illnesses.  (3)  Circidatory  system.  (4)  Digestive  system.  (5) 
Nervous  system.     (6)  Respiratory  system.     (7)  Urinary  system. 

V. — Physical  Examination. — (i)  Urine,  amount,  color,  reaction, 
odor,  specific  gravity ;  albumin,  sugar,  casts,  cells  ;  frequency  of  mic- 
turition ;  pain,  scalding,  bearing-down,  lancinating.  (2)  General  appear- 
ance. (3)  Heart.  (4)  Lungs.  (5)  Abdomen.  (6)  External  genitalia. 
(7)  Perineum.  (8)  Vagina,  cul-de-sac.  (9)  Uterus,  cervix,  position, 
length  ;  patulous  os  and  canal ;  direction  of  long  axis  ;  lacerations ; 
consistency.  Body  of  uterus,  position,  size,  shape,  consistency,  mobility ; 
length  and  direction  of  cavity. 

r  Fallopian  tubes ; 

Appendages,  <  Ovaries ; 

(  Broad  ligaments. 

VI. — Pelvic  Viscera. — Bladder  ;  rectum  ;  anus. 

Positions  for  Examination. — The  various  positions  for  exam- 
ination recommended  are — i,  Erect;  2,  Dorsal;  3,  Semi-prone  (Sims' 
position) ;  4,  Knee-chest ;   5.  Trendelenburg. 

The  erect  position  is  of  limited  value,  and  is  chiefly  employed  in 
detecting  a  slight  degree  of  prolapse  of  the  uterus.  The  patient  is 
asked  to  strain  down  while  in  the  erect  position,  the  examining  finger 
impinging  against  the  cervix.  This  method  may  also  be  employed  in 
the  diagnosis  of  large  tumors  and  in  displacements  of  the  uterus. 
Occasionally  a  pessary  which  will  hold  the  uterus  in  place  in  the  Sims' 
and  dorsal  positions  will  fail  to  do  so  in  the  erect  position. 

The  method  is  employed  as  follows  :  The  examiner  places  himself 
in  front  of  the  patient,  resting  on  his  left  knee ;  the  right  knee  is  semi- 
flexed and  supports  the  right  arm ;  the  left  hand  supports  the  waist, 
and  the  vaginal  examination  is  made  with  the  index  finger  of  the 
right  hand. 

The  dorsal  position  is  the  one  most  frequently  adopted  (Fig.  281). 
The  bladder  and  rectum  should  be  empty  :  the  clothing  should  be 
loose  about  the  waist.     The  table  on  which  the  examination  is  made 


DISEASES  AND   INJURIES    OF  FEMALE    GENERATIVE    ORGANS.     68/ 


should  be  of  convenient  height  and  covered  by  a  blanket  or  cushion. 
The  patient  lies  on  her  back,  her  head  supported  by  a  pillow ;  the  legs 
are  flexed  upon  the  thighs,  and  the  thighs  upon  the  abdomen  ;  the  feet 
should  rest  in  stirrups,  or  the  feet  and 
knees  can  be  supported  by  the  Clover's 
crutch  or  by  an  assistant  on  either  side. 
The  patient  should  be  covered  with  a 
sheet  and  exposed  as  little  as  possible. 
It  is  less  embarrassing  to  the  patient  if 
the  vaginal  examination  be  made  before 
the  inspection  of  the  external  genitals 
or  the  use  of  the  speculum.  The  ex- 
amination should  be  preceded  by  an 
antiseptic  vaginal  irrigation  ;  all  instru- 
ments should  be  sterilized,  and  the 
hands  of  the  examiner  should  be 
thoroughly  cleansed  and  rendered 
aseptic,  special  attention  being  paid  to 
the  finger-nails,  which  should  be  cut 
short  for  fear  of  scratching  the  vaginal 
mucous  membrane.  The  examining 
finger  should  be  covered  with  an 
aseptic  non-irritating  lubricant,  such  as 
green  soap  or  vaselin.  Green  soap  is 
preferred,  because  the  odor  of  the  se- 
cretions can  be  easily  removed  by  wash- 
ing. The  index  finger  of  the  left  hand  is  usually  preferred,  but  it  is 
well  to  cultivate  the  sense  of  touch  in  both  hands. 

The  Semi-prone  or  Sims'  Position  (Fig.  282). — The  patient  lies 
upon  her  left  side,  her  hips  at  the  left-hand  corner  of  the  table.  The 
knees  are  drawn  up  toward  the  chest  as  much  as  possible,  with  the 


Fig.  281. — Woman  in  the  dorsal  posi- 
tion with  feet  supported  in  Edebohls' 
stirrups. 


Fir,.  282. — Sims'  position. 

right  knee  a  little  farther  up  than  the  left  and  almost  touching  the 
table.  The  left  arm  is  drawn  behind  the  patient's  body.  The  knees 
are   to  be  kept  well  flexed. 


688 


Srh'G/C.-lf.    P /A GNOSIS   JXD    TREATMENT. 


The  genu-pectoral  or  knee-chest  position  (Fig.  283)  is  almost 
entirely  confined  to  the  manipulation  for  replacing  a  retroflexed 
uterus.  It  has  been  found  of  service  in  the  operation  for  vesico- 
vaginal fistula,  but  is  open  to  serious  objections,  because  of  the  danger 


Fig.  283. — The  knee-chest  position. 

of  anesthesia  in  this  position.  The  patient  is  placed  upon  a  table ;  the 
weight  of  the  body  is  supported  by  the  knees  (which  are  separated) 
and  the  sides  of  the  face  and  front  of  the  chest ;  the  arms  are  drawn 
back  along  the  sides  of  the  body.  In  this  position  the  patient  is  sup- 
ported by  a  special  appliance  or  by  assistants. 

The  Trendelenburg  position  is  now  very  extensively  used  in  ab- 
dominal operations,  and  consists  in  placing  the  patient  on  her  back, 
with  the  knees  greatly  flexed  and  the  whole  body  and  limbs  so  elevated 
as  to  form  a  steep  incline  from  the  shoulder  to  the  knees  ;  the  back  is 
slightly  arched.     This  position  causes  the  abdominal  to  gravitate  away 

from  the  pelvic  viscera,  thus 
facilitating  operations  in  the 
latter  cavity  (Fig.   284). 

Vaginal  ^Examination. — 
An  antiseptic  vaginal  douche 
should  always  precede  this  ex- 
amination ;  the  bowels  and  blad- 
der should  be  empty,  and  the 
hands  of  the  examiner  sterilized 
as  for  a  surgical  operation. 

The  examination  should  be 
made  in  the  dorsal  position, 
with  the  knees  flexed,  the  feet 
resting  in  stirrups  at  the  sides 
of  the  table  or  supported  by  an 
assistant.  The  index  finger  is 
lubricated  with  green  soap. 
Fig.  284.— Trendelenburg  position.  vasclin,  or   any   antiseptic   non- 

irritating  oil ;  it  is  introduced 
by  first  passing  it  over  the  perineum  into  the  vagina  ;  the  remaining 
fingers  of  the  examining  hand  are  semi-flexed  and  press  against  the  peri- 
neum or  gluteal  fold  ;  the  thumb  is  extended  in  the  direction  of  the  ei'oin. 


DISEASES  AND   INJURIES    OF  FEMALE    GENERATIVE    ORGANS.     689 

The  examining  finger  passes  along  the  posterior  wall  of  the  vagina  till  the 
cervix  is  reached.  Much  information  is  now  gained  as  to  the  degree  of 
sensitiveness  of  the  external  genitals  and  vagina,  the  condition  of  the 
perineum,  the  dryness  and  heat  of  the  vaginal  mucous  membrane,  the 
presence  or  absence  of  the  hymen  and  foreign  growths  of  the  external 
genitalia,  the  existence  of  spasmodic  contraction  of  the  sphincter 
vaginae,  and  the  size  of  the  vagina.  In  palpating  the  cervix  note  the 
size  and  direction  of  its  long  axis,  the  presence  of  lacerations,  and  the 
condition  of  the  os,  whether  patulous  and  soft  or  hard  and  resisting. 
When  the  cervix  cannot  be  easily  reached  the  index  and  middle  fingers 
may  be  inserted  and  greater  pressure  brought  to  bear  upon  the  peri- 
neum. At  times  it  is  more  satisfactory  to  examine  in  the  Sims'  or 
knee-chest  position,  in  order  to  bring  the  cervix  within  reach.  The 
examining  finger  may  be  swept  along  the  sides  of  the  vagina  to  detect 
cicatrices  and  hypertrophied  folds  of  mucous  membrane,  and  along  the 
posterior  wall  to  ascertain  the  condition  of  the  rectum. 

Bimanual    Bxatnination     (Fig.    285). — By    this    method    the 
vaginal  examination  is  greatly  facilitated.     With  the  examining  finger 


Fig.  285. — Bimanual  palpation  of  the  uterus. 


in  the  vagina  and  the  fingers  of  the  other  hand  making  counter-pres- 
sure upon  the  hypogastrium  the  structures  lying  between  the  two 
approximating  fingers  may  be  outlined.  The  exact  position,  size,  and 
degree  of  mobihty  of  the  uterus  are  to  be  demonstrated  by  the  ex- 
amining finger  impinging  against  the  cervix,  while  the  fingers  of  the 
other  hand  make  firm  pressure  in  the  suprapubic  space.     In  extreme 


44 


690 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


retroflexion,  or  where  the  abdominal  wall  is  tense  or  very  thick,  il  may- 
be impossible  to  palpate  the  uterus  in  this  way.  Where  there  is  ex- 
treme sensitiveness  or  rigidity  of  the  abdominal  muscles  anesthesia  is 
indicated.  After  palpating  the  uterus  each  iliac  space  is  to  be  explored. 
The  tubes  are  frequently  felt  as  two  cord-like  bodies  running  from  the 
fundus  of  the  uterus  to  the  sides  of  the  pelvis  ;  these,  when  enlarged 
as  a  result  of  inflammatory  processes  or  tubal  pregnancy,  can  be 
readily  outlined  and  the  degree  of  mobility  demonstrated.  The  ovaries 
lie  beneath  the  di.stal  end  of  the  tubes,  and  under  favorable  conditions 
may  be  felt  as  elastic  oval  bodies  the  size  of  a  pecan-nut.  The  cul- 
de-sac,  in  front,  behind,  and  at  each  side  of  the  uterus,  should  be  care- 
fully palpated  to  detect  the  presence  of  any  foreign  growth,  induration, 
or  point  of  tenderness.  All  foreign  bodies  should  be  carefully  out- 
lined, to  ascertain  their  relation  to  the  uterus,  their  size,  shape,  elasticity, 
and  sensitiveness  to  touch.  This  examination  should  be  made  under 
cover  of  a  sheet. 

Rectal  Kxamination. — Vaginal  or  bimanual  examination  may  be 
supplemented    by  rectal    examination  (Fig.    286).     The  index   finger, 


Fig.  286. — Bimanual  rectal  palpation  of  the  pelvis. 


having  been  previously  lubricated,  is  introduced  into  the  anus  by  a 
rotary  motion  and  firm  pressure  against  the  perineum.  The  fundus, 
the  posterior  surface  of  the  uterus,  and  the  posterior  cul-de-sac  may 
thus  be  palpated.  With  the  other  hand  on  the  abdomen  bimanual 
recto-abdominal  examination  is  made.     This  method  should  never  be 


DISEASES  AND   INJURIES   OF  FEMAIE    GENERATIVE    ORGANS.     69I 

neglected  in  examining  the  pelvic  organs  ;  it  is  especially  indicated  in 
virgins  in  cases  of  imperforate  hymen  and  in  atresia  vaginae. 

Inspection  of  the  Bxternal  Genitalia. — This  should  follow 
the  preceding  examinations.     Hypertrophy  of  the  clitoris  and  vulvae, 


Fig.  287. — Goodell's  speculum. 


Fig.  289. — Nott's  trivalve  speculum. 

vulvitis,  vaginitis,  abscesses  of  the  Bartholinian  glands,  urethral  car- 
uncle, the  character  of  the  leukorrheal  discharge,  the  condition  of  the 
perineum,  and  the  presence  of  hemorrhoids,  rectal  fissures,  strictures, 
and  fistulse,  are  to  be  noted. 

Examination  with  Spcculitin. — Of  the  various  specula  in  the  market, 


692 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


three  varieties  are  adopted  in  general  practice :  i.  Cylindrical  specula. 
These  are  introduced  with  the  patient  occupying  the  dorsal  position, 
and  are  of  service  in  making  topical  applications  to  the  cervix  and 
uterus,  but  they  have  these  objections — viz.  they  do  not  permit  of  an 
unobstructed  view  of  the  anterior  wall  of  the  vagina ;  they  inflict  pain 
where  the  vagina  is  small  and  sensitive ;  and  their  lumen  is  too  small 
to  admit  of  free  instrumental  manipulation. 

2.  The  bivalve  speculum  is  most  serviceable  in  general  practice 
where  an  assistant  is  not  at  hand.  The  best  in  the  market  are  Good- 
ell's  (Fig.  287),  Brewer's  (Fig.  288),  and  Nott's  (Fig.  289).  They  are 
introduced  in  the  dorsal  position,  and  afford  a  view  of  the  cervix,  cul- 
de-sac,  and  anterior  vaginal  wall. 

3.  Sims'  speculum  (Fig.  290)  where  there  is  an  assistant  affords  the 


Fig.  290. — Sims'  speculum. 

greatest  advantage ;  it  permits  of  a  maximum  amount  of  room  in  the 
vagina ;  the  view  of  the  cervix  and  anterior  vaginal  wall  is  not  ob- 
structed ;  it  is  easily  introduced,  and  facilitates  and  renders  possible 
many  operations  upon  the  vagina,  cervix,  and  uterus,  As  a  rule,  it  is 
used  in  the  Sims  position. 

Simon's  hollow  blades,  mounted  upon  a  handle  and  made  in  sets 
of  various  sizes,  are  useful. 

Uterine  Sound. — The  simplest  uterine  sound  is  the  best;  it  has  a 
graduated  flexible  stem,  a  button  end,  and  a  spatula-shaped  handle. 
The  uterine  sound  should  never  be  used  without  first  ascertaining  the 
size,  shape,  position,  and  condition  of  the  uterus  by  bimanual  examina- 
tion, and  after  positively  excluding  the  question  of  pregnancy. 

The  probe  should  be  bent  to  correspond  with  the  curve  of  the  cav- 
ity of  the  uterus.  Before  introducing  it  irrigate  the  vagina  with  an 
antiseptic  solution  and  wipe  the  cervical  canal  with  pledgets  of  cotton. 
The  probe  must  be  sterilized,  the  patient  placed  in  the  dorsal  position, 
and  a  speculum  inserted. 

Gentle  traction  on  the  cervix  with  a  tenaculum  by  straightening  the 
canal  aids  the  introduction  of  the  probe  and  brings  the  os  into  view  and 
within  reach.  Before  withdrawing  the  probe  the  depth  of  the  cava  uteri 
and  the  length  of  the  cervix  can  be  measured  by  placing  the  finger  on 
the  probe  at  the  os  externum  or  catching  it  at  this  point  by  forceps. 
The  probe  demonstrates  the  length  and  width  of  the  uterine  canal,  the 
direction  of  its  long  axis,  and  the  patency  of  the  canal.  The  probe 
should  never  be  used  in  correcting  a  retroflexed  uterus,  for  fear  of 
injury  to  the  organ.   Metritis,  perimetritis,  and  salpingitis  have  followed 


DISEASES  AND   L\JURIES   OF  FEMALE    GENERATIVE    ORGANS.     693 

its  use,  but  such  consequences  are  rare,  and  the  instrument  remains  a 
valuable  aid  to  diagnosis,  especially  to  the  inexperienced. 

Artificial  Dilatation  of  the  Uterus. — The  uterus  should  be 
dilated  with  the  strictest  of  aseptic  precautions.  The  following  methods 
are  in  vogue : 

1.  Gradual  dilatation  by  tents  made  of  sponge,  tupelo,  slippery  elm, 
or  laminaria.  This  method  cannot  be  recommended  except  in  special 
cases,  because  of  the  difficulty  in  thoroughly  sterilizing  the  tents. 

2.  Instruuicnts   of  Diviilsion. — Ellinger's,  or  Goodell's    (Fig.    291) 


Fig.  291. — Goodell's  modification  of  Ellinger's  dilator. 

modification  of  Ellinger's,  dilator  is  the  best  and  safest  of  all  means  of 
rapid  dilatation  of  the  cervix.  The  operation  should  require  ten  to 
thirty  minutes,  depending  upon  the  rigidity  of  the  cervix.  Anesthesia 
is  unnecessary,  except  where  dilatation  is  to  be  complete. 

3.  Immediate  Progressive  Dilatation. — Of  the  instruments  employed 
for  this  purpose,  Hagar's  cylindrical  bougies  are  the  best.  Tait's  coni- 
cal form  and  Hanks's  hard-rubber  and  ovoid  form  are  also  recommended 
(Fig.  292).     They  may  be  passed  in  the  dorsal  or  Sims  position.     The 


Fig.  292. — Hanks's  large  uterine  dilator. 

vagina  is  first  irrigated  and  the  speculum  introduced.  Lubricate  the 
sterilized  bougies  with  sterilized  vaselin  ;  begin  with  the  size  which  will 
pass  with  least  resistance,  and  gradually  dilate  by  successively  intro- 
ducing the  next  larger  size.  When  one  is  found  to  enter  with  difficulty, 
leave  it  in  place  for  a  few  minutes  till  the  spasmodic  contraction  has 
passed  away,  then  proceed  to  the  next  larger. 

4.  Incision. — Where  in  urgent  cases  the  preceding  methods  have 
failed,  and  the  only  point  of  constriction  is  at  the  external  os,  one  or 
more  incisions  may  be  made  at  the  point  with  scissors,  and  closed  with 
sutures  later. 


694  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

5.  Complete  Bilateral  Divisio)i  of  the  Cei'vix. — This  mcthed  is  rarely- 
resorted  to,  and  is  only  indicated  in  case  of  the  extraction  of  large 
intra-uterine  growths,  where  the  cervical  canal  resists  dilatation  or  where 
the  rigid  cervix  resists  the  above  methods  and  the  indications  for 
dilating   are  urgent. 

6.  Where  time  is  no  factor  the  uterus  may  be  packed  with  iodo- 
form gauze — the  gauze  removed  in  forty-eight  hours  and  more  replaced 
till  sufficient  dilatation  has  been  effected. 

When  it  is  necessary  to  make  a  microscopic  examination  of  uterine 
tissue,  a  wedge-shaped  piece  can  be  removed  or  the  uterus  can  be 
dilated  and  curetted,  and  the  product  of  the  curettage  examined  by 
allowing  it  to  float  in  water,  after  which  it  can  be  placed  under  the 
microscope. 

Bxamination  of  the  Urethra  and  Bladder. — In  pelvic  dis- 
orders in  the  female  the  urethra  and  bladder  are  frequently  involved 
and  should  be  carefully  examined.  A  thorough  examination  of  the 
urine  should  never  be  omitted. 

1.  Inspeetion. — By  inspection  urethral  caruncles,  prolapse  of  the 
mucous  membrane  of  the  urethra,  stricture  of  the  urethra,  urethrocele, 
cystocele,  and  the  secretions  from  the  urethra  may  be  observed. 

2.  Palpation. — By  vaginal  and  bimanual  palpation  the  relative  posi- 
tion of  the  bladder  and  uterus,  the  degree  of  distention  of  the  bladder, 
stone  in  the  urethra  and  bladder,  and  tender  points  in  the  urethra  should 
be  sought  for. 

3.  Sound. — By  the  sound  the  presence  and  site  of  stricture  of  the 
urethra  can  be  demonstrated,  though  stricture  in  the  female  is  of  com- 
paratively rare  occurrence.  Also  by  the  sound  sensitive  points  along 
the  urethra,  due  to  inflammation  and  ulcers,  are  detected. 

4.  Endoscope. — Skene's  endoscope  is  almost  invariably  used,  and 
consists  of  a  small  glass  test-tube,  which  is  first  passed  as  far  as  the 
bladder;  into  this  tube  is  inserted  a  mirror  obhquely  placed  on  a 
handle,  by  which  it  is  turned  in  all  directions,  and  with  artificial  light 
directed  upon  it  from  a  hand-mirror  the  entire  mucous  membrane  of 
the  urethra  can  be  inspected ;  in  this  manner  direct  inspection  can  be 
made  of  fissures,  ulcers,  and  inflammation. 

Digital  examination  of  the  urethra  and  bladder  may  be  made  with- 
out injury  by  gradually  dilating  with  Simon's  dilators,  and  then  intro- 
ducing the  index  finger. 

Bxamination  of  the  Ureters. — The  pelvic  portions  of  the  ure- 
ters may  be  palpated  by  bimanual  examination,  and  are  felt  as  cord- 
like bands  running  from  the  sides  of  the  bladder  upward  and  back- 
ward to  the  bases  of  the  broad  ligaments.  The  abdominal  portion  of 
the  ureters  may  be  palpated  by  passing  a  ureteral  catheter  to  the  pelvis 
of  the  kidney. 

Method  of  Catheterizing  the  Ureters. — The  patient  is  placed  in 
the  dorsal  position,  with  the  pelvis  close  to  the  edge  of  the  table  and 
the  legs  and  thighs  strongly  flexed.  The  bladder  is  emptied  by  a 
catheter,  and  the  urine  set  aside  for  comparison  with  what  is  to  be 
obtained  later.  About  200  c.c.  of  an  anilin  solution  is  injected  into  the 
bladder.  The  posterior  vaginal  wall  is  now  retracted  with  a  Sims  or 
Simon  speculum,  and  a  full  view  of  the  anterior  wall  obtained.     Over 


DISEASES  AND   INJURIES   OF  FEMALE    GENERATIVE    ORGANS.     695 

the  anterior  surface  of  the  wall,  and  about  halfway  up/will  be  seen  two 
prominent  folds  sweeping  outward  on  to  the  lateral  walls  in  the  direc- 
tion of  the  cervix.  These  are  Pawlik's  ureteral  folds,  and  just  above 
and  running  parallel  to  them  are  the  ureters.  The  ureteral  catheter  is 
now  introduced,  and  its  point  turned  toward  the  floor  of  the  bladder, 
where  by  slight  pressure  its  position  can  be  felt  by  the  finger  or  seen 
by  the  eye.  The  point  of  the  instrument  is  now  made  to  sweep  out- 
ward in  the  direction  of  the  ureteral  fold  in  search  of  the  ureteral  open- 
ing. When  once  engaged  in  the  opening  the  catheter  is  slipped  back- 
ward and  outward  toward  the  posterior  pelvic  wall.  It  can  then  be 
pushed  as  far  as  the  pelvis  of  the  kidney.  From  the  vagina  the  ureter 
can  now  be  palpated  with  the  finger.  In  a  few  moments  urine  begins 
to  flow  from  it  in  little  jets.  The  urine  is  also  free  from  the  color 
of  the  fluid  which  was  injected  into  the  bladder,  proving  that  it  comes 
from  a  higher  source. 


II.  ANOMALIES  OF  THE  FEMALE  GENITAL  ORGANS. 

True  hermaphrodism  is  a  congenital  anomaly  in  which  there  is  a 
union  of  characteristics  of  the  two  sexes  in  the  same  individual :  the 
tendency  is  toward  the  male  type.  Klebs  divided  true  hermaphrodism 
into — I.  Bilateral — an  ovary  and  testicle  on  both  sides;  2.  Unilateral — 
on  one  side  an  ovary  and  a  testicle,  on  the  other  side  an  ovary  or  a 
testicle ;   3.  Lateral — ovary  on  one  side,  testicle  on  the  other. 

In  apparent  or  pseudo-hermaphrodism  the  female  may  simulate  the 
male  type  in  one  or  more  of  the  genital  organs,  which  are  excessively 
developed,  as  in  the  case  of  an  enormously  developed  clitoris,  simulat- 
ing the  penis,  and  a  hernial  descent  of  the  ovary  into  the  labial  fold, 
simulating  the  testicle  ;  or  the  male  organs  may  simulate  the  female 
organs,  as  in  hypospadias,  the  fissure  of  the  corpora  cavernosa  being 
mistaken  for  the  vagina,  and  an  atrophied  penis  may  be  mistaken  for 
the  clitoris. 

Anomalies  of  the  External  Genital  Organs. — Vulva. — 
Atresia  is  rarely  seen  in  the  vestibule.  A  complete  absence  of  the 
vulva,  with  the  skin  stretched  over  the  entire  region,  is  a  rare  mal- 
formation. 

Hypospadia  in  the  female  is  a  very  rare  congenital  defect,  and  is  due 
to  arrested  development  of  the  urogenital  sinus,  resulting  in  the  forma- 
tion of  a  common  outlet  of  the  vagina  and  rectum  ;  more  commonly  the 
rectum  opens  into  the  vagina — a  condition  known  as  aiio-vaginalis. 

Non-dcvclopuioit  of  the  Vulva. — This  condition  usually  coexists 
with  a  failure  of  development  of  the  internal  genital  organs,  and  con- 
sists of  a  thin  flattened  labia,  a  narrow  flattened  vestibule,  a  small 
clitoris,  and  imperfectly  developed  mons  veneris  and  pubic  hair. 

Hypertrophy  of  the  Vulva. — Thickened  labia  majora  are  of  rare 
occurrence  and  do  not  demand  operative  interference. 

Hypertrophied  labia  minora,  or,  more  rarely,  supernumerary  labia 
minora,  when  they  become  inflamed,  tender,  and  interfere  with  coition 
and  locomotion  should  be  excised. 

Anomalies  of  the  Hymen. — The  normal  hymen  is  a  thin  con- 
centric membrane  guarding  the  outlet  of  the  vagina  and  perforated  in 


696  SURGICAL   DIAGNOSIS   AND    TREATMENT. 

the  center  by  an  opening  lart^e  enough  to  admit  the  Httle  finger.  The 
following  anomalies  are  found:  i.  The  hymen  maybe  absent  or  repre- 
sented merely  by  one  or  more  papilla;.  2.  Imperforate  hymen,  the 
membrane  completely  closing  the.  vaginal  outlet.  3.  Where  the  per- 
foration is  very  small  or  there  are  a  number  of  small  perforations,  the 
so-called  cribriform  hymen.  4.  Hypertrophied  hymen,  where  the 
membrane  protrudes  through  the  vulvar  outlet.  5.  Serrated  hymen, 
where  the  free  margin  is  dentated.  6.  Thickened  hymen,  where  the 
membrane  is  tough  and  resisting ;  coition  and  even  labor  may  occur 
without  rupturing  the  thickened  h}-mcn. 

Hypertrophy  of  the  Clitoris. — The  clitoris  may  become  so 
large  as  to  simulate  the  penis.  When  it  becomes  inflamed  or  irritated, 
and  causes  discomfort  in  walking  or  interferes  with  coition,  amputation 
of  the  clitoris  is  indicated. 

Anomalies  of  the  Internal  Genital  Organs. — The  vagina 
varies  greatly  in  length  and  breadth.  There  may  be  complete  or 
partial  atresia  of  the  canal,  with  or  without  a  developed  uterus.  The 
vagina  may  exist  merely  as  a  fibrous  and  muscular  band,  or  it  may  be 
partially  or  completely  divided  by  a  septum  antero-posteriorly  or 
laterally.  A  so-called  second  hymen  may  exist — that  is,  a  membrane 
stretched  across  the  vagina  above  the  hymen,  and  which  partially  or 
completely  divides  the  canal  into  an  upper  and  lower  segment.  If 
there  be  complete  atresia  of  the  vagina  with  a  perfectly  formed  uterus, 
tubes,  and  ovaries,  the  menstrual  secretions  will  be  retained ;  the  pain 
resulting  will  be  increased  at  each  menstrual  period;  the  vagina  will 
become  distended  with  blood,  and  must  be  emptied  through  an  arti- 
ficial outlet.  The  operation  consists  in  making  a  transverse  incision  in 
the  perineum  between  the  rectum  and  urethra ;  the  tissues  are  dissected 
up  to  the  cervix  or  uterus  by  a  blunt  instrument  or  the  finger,  and  if 
the  cervix  is  found  patent  it  should  be  dilated.  If  the  cervix  is  closed, 
the  uterus  may  be  punctured  with  a  trocar,  the  opening  enlarged  by 
stretching  with  bougies  or  by  taking  a  flap  of  skin  from  the  buttocks 
and  attaching  it  to  the  margin  of  the  artificial  opening  in  the  uterus. 
When  there  are  no  menstrual  secretions  from  an  undeveloped  uterus 
and  appendages,  no  operative  interference  is  indicated.  If  from  the 
presence  of  the  ovaries  great  menstrual  disturbance  results,  the  ope- 
ration of  ov^ariotomy  may  be  indicated. 

Anomalies  in  Development  of  the  Cervix. — Anomalies  are  frequently 
found  in  the  development  of  the  cervix  and  in  the  size,  shape,  and 
degree  of  patency  of  the  os  and  canal. 

Stenosis  of  the  cervical  canal  is  of  the  greatest  clinical  importance. 
This  condition  is  often  associated  with  a  small  cervix  and  fundus  and 
anteflexion.  As  a  result  of  the  obstructed  menstrual  flow,  dysmenor- 
rhea, endocervicitis,  and  endometritis  develop,  rendering  the  patient 
sterile.  The  treatment  consists  in  gradual  dilatation  of  the  cervix  by 
instruments  of  divulsion,  followed  by  curetting.  The  operation  should 
be  done  under  anesthesia. 

Atresia  of  the  Cervix. — This  condition  may  be  congenital  or  ac- 
quired, and  may  affect  the  os  externum,  the  os  internum,  or  the  whole 
cervical  canal.  In  the  congenital  variety  the  condition  is  rarely  noticed 
before  puberty,  at  which  time  the  menstrual  secretions  collect  and  cause 


DISEASES  AND  INJURIES   OF  FEMALE    GENERATIVE    ORGANS.     697 

dysmenorrhea.  The  diagnosis  is  readily  made  by  an  attempt  to  pass 
a  sound  and  by  the  distended  uterus  and  tubes,  which  are  felt  by 
bimanual   examination. 

The  acquired  form  may  result  from  the  use  of  caustics,  from  ulcera- 
tion and  inflammatory  processes,  and  rarely  from  unknown  causes. 
(For  treatment  see   Hematometra.) 

Arrested  Dcvelopuicut  of  the  Cervix. — The  cervix  may  be  absent  or 
only  partially  developed.  The  vaginal  portion  may  be  wanting,  a  con- 
dition which  may  exist  alone  or  together  with  a  failure  in  the  develop- 
ment of  other  parts  of  the  genital  tract. 

Hvpcrtropliy  of  the  Cervix. — Congenital  hypertrophy  of  the  vaginal 
portion  of  the  cervix  occasionally  exists  ;  the  cervix  may  protrude  from 
the  vulvar  outlet,  become  inflamed,  and  interfere  with  locomotion  and 
coition,  in  which  case  Hagar's  amputation  of  the  cervix  should  be 
performed. 

Anomalies  of  the  Uterus. — Anomalies  of  the  uterus  chiefly 
arise  from  arrested  development  of  the  organ,  and  consist  of  a  greater 
or  less  duplicity  of  the  uterus  from  partial  or  complete  failure  of  the 
duct  of  Miiller  to  unite.  When  development  has  been  arrested  at 
a  very  early  stage  there  may  be  entire  absence  of  the  uterus,  or  it 
may  be  represented  by  a  mere  bundle  of  muscle  and  connective- 
tissue  fibers.  If  arrested  late  in  the  development,  the  organ  simply 
remains  in  the  infantile  state.  When  it  fails  to  develop  at  puberty,  there 
is  often  associated  with  infantile  uterus  anteflexion  and  an  hysterical 
temperament ;  the  ovaries  may  be  fully  developed  and  the  menstrual 
periods  recur  with  more  or  less  regularity,  but  there  are  menstrual  dis- 
turbances which  may  be  so  severe  as  to  demand  ovariotomy.  The 
treatment  of  infantile  uteri  is  not  satisfactory  :  the  faradic  current  has 
been  applied  to  the  interior  of  the  uterus,  but  the  dysmenorrhea  and 
sterility  may  be  considered  incurable. 

From  failure  of  development  and  from  a  failure  of  Muller's  duct 
to  unite  the  following  anomalies  may  result : 

1.  Uterus  unicornis,  where  one  Muller's  duct  is  absent  or  partially 
developed,  the  uterus  consisting  of  but  one  side.  There  is  but  one 
tube,  but  both  ovaries  may  be  well  developed.  No  treatment  is 
indicated. 

2.  Uterus  didelphys,  double  uterus.  In  this  condition  there  are  two 
separate  and  distinct  uteri. 

3.  Uterus  bicornis  duplex.  In  this  form  there  are  two  vaginae,  two 
ovaries,  and  two  uteri,  joined  externally  by  bands  of  connective  tissue 
and  peritoneum. 

4.  Uterus  bicornis,  unicollis  bifid.  There  is  but  one  vagina  and  one 
cervix,  but  two  uteri,  the  Muller's  duct  having  united  to  a  variable 
distance,  but  failing  to  unite  above. 

5.  Uterus  cordiformis.  As  the  name  implies,  the  uterus  is  heart- 
shaped  ;  the  partial  failure  of  fusion  is  shown  in  the  presence  of  a  de- 
pression in  the  broadened  fundus  uteri,  there  being  but  one  uterus,  one 
cervix,  and  one  vagina. 

6.  Without  any  external  manifestations  the  uterine  cavity  may  be 
divided  by  a  septum  into  two  compartments,  or  this  septum  may  only 
partially  divide  the  cavity. 


698  srRGICAL   D/AGXOS/S  AXD    TREATMENT. 

Anomalies  of  the  Fallopian  Tubes. — These  are  of  little  prac- 
tical interest  to  the  gynecologist.  There  may  be  two  tubes  separated 
throughout,  or  two  or  more  fimbriated  extremities  on  one  tube  ;  there 
may  be  two  openings  into  the  uterus  with  a  single  tube ;  the  lumen  of 
the  tube  ma}'  be  unusuall\-  large  or  small,  or  even  absent. 

Anomalies  of  the  Ovaries. — The  ovary  may  be  altogether  \\ant- 
ing  or  unusually  small ;  there  may  be  one  or  more  supernumerary 
ovaries,  or  in  an  apparently  normal  ovary  the  Graafian  follicles  and  ova 
may  be  absent. 

III.  TRAUMATIC  LESIONS  OF  THE  FEMALE  GENITAL  TRACT. 

Injuries  of  the  Vulva  and  Perineum. — These  injuries  may  be 
due  to — I.  External  violence,  as  from  a  blow,  fall,  kick,  or  coitus.  2. 
Parturition.  When  the  skin  has  been  torn  the  hemorrhage  may  be  free 
and  even  dangerous,  and  where  the  skin  remains  intact  the  blood  may 
collect  in  the  loose  subcutaneous  connective  tissue,  causing  a  tumor, 
discoloration,  and  pain — the  so-called  pudendal  hematoma.  Injuries  in 
the  region  of  the  clitoris  are  often  dangerous  because  of  the  great  vas- 
cularity of  the  part. 

Treatment. — If  there  is  simple  contusion,  rest  and  cold  applications 
will  suffice  ;  when  hematoma  exists,  rest  in  bed  and  firm,  soft  pressure 
will  promote  the  resorption  of  the  clot.  Where  suppuration  develops, 
strict  antiseptic  precautions  should  be  resorted  to,  the  abscess  opened 
and  drained,  and  a  sterilized  dressing  wath  T-bandage  applied.  Hemor- 
rhage, as  a  rule,  can  be  controlled  by  pressure  from  sterilized  gauze ;  if 
not.  the  vessels  may  be  Hgated  or  the  tissues  tied  en  masse. 

Injuries  of  the  Vagina. — These  injuries  are  rare,  and  occur  from 
coitus,  from  blows,  kicks,  and  falls. 

Treatment  consists  in  giving  a  thorough  antiseptic  vaginal  douche, 
followed  by  packing  with  iodoform  gauze  or  by  suturing  the  lacerated 
surface  with  silk  or  catgut,  dusting  with  iodoform  powder,  and  dress- 
ing with  iodoform  gauze.  The  cervix  is  seldom  injured  by  causes  other 
than  parturition. 

Injuries  due  to  Parturition. — Vulva  and  Perineum. — The  vulva 
and  perineum  are  frequently  injured  during  labor  from  mechanical  inter- 
ference, by  the  use  of  the  forceps,  or  by  the  causes  of  natural  dystocia, 
including  a  relatively  large  presenting  body  or  a  relatively  small  out- 
let ;  also  by  any  undue  measures  taken  for  the  purpose  of  hastening 
the  progress  of  labor,  as  ergot  and  rupture  of  the  bag  of  waters  before 
the  completion  of  dilatation.  The  perineum  being  the  true  support  of 
the  pelvic  organs,  such  injuries  are  of  the  highest  importance  in  the 
causation  of  pelvic  disorders.  Too  much  stress  has  been  laid  upon 
injuries  of  the  perineum  as  the  causal  factor  of  many  female  diseases. 
Many  cases  are  seen  where  the  injury  has  existed  for  years,  and  yet 
the  woman  suffers  no  inconvenience  ;  on  the  other  hand,  injuries  of 
the  perineum  are  frequently  the  starting-point  of  subsequent  ailments, 
and  repair  of  the  injury  has  resulted  in  complete  relief 

These  injuries  cannot  always  be  prevented,  but  by  avoiding  all  per- 
nicious means  of  hastening  labor,  by  allowing  the  bag  of  waters  to 
rupture  spontaneously,  and  by  protecting  the  perineum  in  the  second 


DISEASES  AND  IXJURIES   OF  FEMALE    GENERATIVE    ORGANS.     699 

stage  of  labor  many  injuries  will  be  prevented  which  would  otherwise 
occur. 

Varieties. — The  injuries  may  be  submucous  and  subcutaneous,  but, 
as  a  rule,  both  the  mucous  membrane  and  the  skin  are  divided.  For 
the  sake  of  convenience  of  description  three  degrees  are  recognized : 
First  degree,  a  rupture  extending  part  way  to  the  sphincter  ani ; 
second  degree,  a  rupture  extending  to  the  sphincter  ani ;  third  de- 
gree, a  rupture  extending  through  the  sphincter  ani  and  including 
more  or  less  of  the  recto-vaginal  septum.  The  rupture  may  be  in  the 
median  line,  may  be  transverse  to  the  median  line,  or  may  pass  around 
the  sphincter  ani. 

SvDiptoms. — The  symptoms  are  all  referred  to  the  lack  of  support 
to  the  pelvic  organs  ;  there  is  a  feeling  of  weight  and  insecurity  in 
the  pelvis.  The  posterior  vaginal  wall  may  bulge  forward,  giving 
rise  to  the  formation  of  a  rectocele,  which  interferes  with  the  function 
of  the  rectum,  a  great  effort  being  required  to  effect  a  movement  of  the 
bowels,  and  this  effort  seems  to  exaggerate  the  condition.  The  ante- 
rior vaginal  wall  may  become  thickened  and  bulge  backward ;  this 
condition  is  known  as  vesicocele,  which,  if  it  includes  the  bladder, 
may  seriously  interfere  with  the  evacuation  of  that  viscus.  The  residual 
urine  collects  in  the  pouching  bladder,  becomes  ammoniacal,  and  gives 
rise  to  a  cystitis ;  hypertrophy  and  prolapse  of  the  vagina  result  to  a 
greater  or  less  degree  and  augment  the  above  conditions.  Great  annoy- 
ance to  the  patient  may  arise  from  the  entrance  and  forcing  out  of  the 
air  in  the  vagina.  Displacement  of  the  uterus  follows  the  loss  of  sup- 
port afforded  by  the  perineum.  Many  vague  reflex  symptoms  referred 
to  the  pelvis,  abdomen,  chest,  and  limbs  have  been  credited  to  the  in- 
jury to  the  perineum.  Where  there  is  a  complete  laceration  through 
the  sphincter  ani  there  is  a  loss  of  control  over  the  bowels,  the  feces 
and  gas  escape  without  warning  and  without  control,  and  the  life  of 
the  indiv'idual  becomes  a  burden.  An  irritating  mucous  discharge 
from  the  inflamed  rectum  may  complicate  lacerations  which  involve  the 
bowel. 

It  will  thus  be  seen  that  the  injury  is  associated  with  general  relaxa- 
tion of  the  tissues  of  the  pelvis.  When  examining  for  a  lacerated  peri- 
neum the  labia  should  be  separated  by  the  fingers  and  the  posterior 
vaginal  wall  inspected,  since  the  greatest  injury  is  found  at  this  site. 

Treatment. —  i.  Primary  or  Immediate  Operation. — In  general  it  may 
be  said  that  every  lacerated  perineum  should  be  repaired  at  the  earliest 
possible  date.  The  time  should  not  exceed  six  hours  after  the  rupture, 
though  twelve  to  forty-eight  hours  have  elapsed  and  perfect  results 
been  obtained.  Much  argument  is  waged  over  the  advisability  of  re- 
pairing lacerations  of  the  third  degree  immediately  after  labor,  but  there 
seems  to  be  no  reason  to  justify  delay  or  unnecessary  operative  inter- 
ference in  these  lacerations.  The  patient  should  be  brought  to  the 
edge  of  the  bed,  with  the  legs  flexed  upon  the  thighs  and  the  thighs 
flexed  upon  the  abdomen,  the  limbs  supported  by  assistants.  A  catgut 
suture  is  used,  passing  from  one  side  of  the  laceration  to  the  other,  in- 
cluding the  whole  of  the  lacerated  tissue:  about  half  an  inch  in  front 
of  this,  if  required,  another  suture  may  be  inserted  ;  the  sutures  should 
be  buried  throughout. 


700 


SURGICAL   DIAGNOSIS  AND    ll^EATMENT. 


Fig.  293. — Diagram  of  opera- 
tion for  simple  rupture. 


2.  Scco)idarv  Operation. — The  secondary  operation  should  not  be 
performed  short  of  three  months  after  tlie  injury,  because  before  that 
time  involution  has  not  sufficiently  prot^ressed. 

{(.i)  Iiicoiiipli'tc  Laceration  (Fig.  293). — A  laxative  should  be  giv^en 
the  day  previous  and  an  enema  an  hour  or  two  before  the  operation ; 

the  pubic  hair  should  be  shaved  and  the  ex- 
ternal genitals  scrubbed  with  soap  and  water, 
and  sterilized  by  antiseptic  solutions ;  a  vagi- 
nal douche  of  bichlorid  i  :  2000  should  be 
given,  and  the  patient  anesthetized  and  placed 
in  the  dorsal  position,  with  the  legs  supported 
by  a  Clover's  crutch  or  by  assistants. 

The  surface  to  be  denuded  is  first  outlined 
by  a  pair  of  angular  scissors  ;  the  line  of  incis- 
ion will  correspond  to  a  line  formed  by  continu- 
ing the  hymen  around  to  the  corresponding 
side,  carrying  the  upper  border  on  each  side  to 
a  point  just  below  the  level  of  the  anterior  vagi- 
nal w^all.  The  index  finger  of  the  left  hand 
should  be  inserted  into  the  rectum  as  a  guide. 
The  surface  to  be  denuded  is  variable  and  should 
extend  to  the  crest  of  the  rectocele.  Hemor- 
rhage may  be  checked  by  continual  irrigation 
or  by  sponges,  and  the  denuded  surfaces 
brought  into  apposition  by  sutures,  beginning  at  the  lowest  point  and 
passing  from  near  the  anal  margin  on  the  right  side,  through  the  recto- 
vaginal septum,  to  a  corresponding  point  on  the  opposite  side.  Other 
sutures   are   passed   in   front   of  this   at   regular  intervals ;   the   upper 

sutures  are  passed  under  the  reflected  surface. 
The  sutures  are  then  tightened,  beginning  from 
below,  care  being  taken  not  to  draw  them  too 
tight  for  fear  of  cutting  through  the  tissues. 
Silk  or  silkworm  gut  may  be  used. 

Aftci'-tn-atnicnt. — The  patient  should  re- 
main in  bed  two  weeks,  the  urine  being  drawn 
by  a  catheter  for  three  days,  and  the  bowels 
opened  about  the  second  day  either  by  a  mild 
cathartic  or  enema,  and  kept  open.  The  wound 
is  dressed  by  dusting  with  boric-acid  powder  or 
iodoform  powder,  and  over  this  is  applied  a 
sterilized  absorbent  dressing  retained  by  a 
T-bandage.  The  stitches  are  removed  by  the 
seventh  to  the  tenth  day. 

{b)  Complete  Rupture  (Fig.  294). — Wlien 
the  sphincter  ani  and  the  recto-vaginal  sep- 
tum are  divided,  these  structures  must  first  be 
united  by  sutures,  care  being  taken  to  accu- 
rately approximate  the  divided  ends  of  the  sphincter  ani.  The  divided 
margins  are  denuded  by  the  scissors  or  knife,  the  stitch  passed  from  the 
vaginal  side  and  including  the  entire  recto-vaginal  fold,  penetrating  at 
the  upper  and  inner  divided  end  of  the  sphincter,  and  returning  at  cor- 


FlG.  294. — Diagram  of  opera- 
tion for  complete  rupture. 


DISEASES  AND   INJURIES   OF  FEMALE    GENERATIVE    ORGANS.     70I 


responding  points  at  the  opposite  side,  passing  from  within  outward. 
With  one  or  more  of  these  sutures  in  place  and  tied,  the  perineum  in 
front  of  the  sphincter  is  repaired  as  in  incomplete  rupture.  The  pre- 
paratory and  after-treatment  is  the  same  as  in  incomplete  rupture ; 
great  care  should  be  taken  in  giving  a  rectal  enema  not  to  disturb  the 
wound  by  the  irrigating  tube. 

Emmet's  Operation — Semilimar  or  B7itterfly  Operation. — This  opera- 
tion is  indicated  in  transverse  lacerations  and  where  there  is  relaxation 
of  the  soft  parts ;  it  is  intended  to  restore  the  severed  tissues  and  to 
contract  those  which  are  over-distended  and  relaxed.  In  transverse 
laceration  the  levator  ani  and  fascia  are  separated  from  the  perineum 
proper ;  this  operation  is   devised  to   reunite  these  structures. 

In  denuding  the  surface  two  landmarks  are  to  be  kept  in  mind :  one 
is  the  line  of  the  hymen,  and  the  other  is  a  sulcus  which  is  found  at 
each  side  and  forms  a  depression  between  the  center  and  side  of  the 
vagina.  There  is  always  a  rectocele  in  these  cases,  and  this  also  plays 
an  important  part  in  the  operation.  The  patient  is  placed  in  the  dorsal 
position,  as  in  the  previous  operation.  The  denudation  is  begun  by 
following  the  line  of  the  hymen  or  a  little  outside  of  it,  and  beginning 
near  the  posterior  commissure,  running  up  the  labium  to  a  level  with 
the  lower  edge  of  the  meatus.  The  line  is  then  carried  along  the  side 
of  the  vagina  and  well  up  into  the  sulcus  on  each  side.  The  rectocele 
is  next  denuded  by  following  the  median  line  of  the  vagina  as  far  as  the 
rectocele  extends.  The  denuded  area  assumes  a  shape  seen  in  Fig.  295. 
In  placing  the  sutures  begin  at  the  upper  angle  of  one  sulcus.  Pass 
the  stitch  from  the  outside,  not  straight  across,  but  downward  and  in- 
ward, to  about  the  middle  of  the 
denuded  area ;  then  pass  it  upward 
and  outward  to  a  point  on  the  unde- 
nuded  surface  of  the  posterior  vaginal 


y!^\_ 


Fig.  295.— Area  of  denudation  i^ 
Emmet's  operation. 


Fig.  296. — Area  of  denudation  and  method  of 
placing  stitches. 


wall  which  corresponds  with  the  point  at  which  the  needle  entered. 
Three  to  five  stitches  are  needed,  and  they  can  be  interrupted  or  of 
continuous  catgut.  The  other  sulcus  is  treated  in  the  same  manner 
(Fig.  296).  All  that  is  left  now  is  a  raw  surface  posteriorly,  which  is 
closed  by  stitches  placed  in  the  manner  adopted  for  the  incomplete 
laceration. 


7o: 


SURGICAL    DIAGjYOSIS  AND    TREATMENT. 


Flap-splittiiiij;  operation  of  'fait. — This  opcmlion  is  only  indicated  in 
superficial  laceration  of  the  perineum  :  it  will  not  remove  a  rectocele  or 


Fig.  297. — Flap-splitting  for  incomplete  laceration  of  the  perineum  :  relaxation  of  the  vaginal 

outlet  (Macphatter). 

narrow  the  vagina,  hence  its  field  of  usefulness  is  limited  indeed.     The 
operation  is  thus  described  in  the  American  Text-Book  of  Gynecology  : 


Fig.  298. — Flap-splitting    for    complete    laceration  of   the  perineum:    laceration  through  the 
sphincter  ani  muscle   (Macphatter). 

"  For  Incomplete  Laceration  (Fig.  297). — The  index  finger  of  the  left 
hand  being  introduced  into  the  rectum  as  a  guide,  the  point  of  one  of 


DISEASES  AND  INJURIES   OF  FEMALE    GENERATIVE    ORGANS.     703 

the  blades  of  the  scissors  is  thrust  into  the  recto-vaginal  septum,  mid- 
way between  the  vaginal  opening  and  the  anus,  to  the  depth  of  half  an 
inch  or  more,  care  being  taken  that  the  instrument  enters  neither  the 
vagina  nor  rectum.  From  this  point  the  incision  is  made,  first  to  one  side 
and  then  to  the  other.  The  line  of  the  incision  is  carried  on  one  side 
outward  and  upward  along  the  boundary-line  between  the  vaginal 
mucous  membrane  and  the  skin  of  the  labium.  It  is  extended  up  the 
labium  to  that  point  at  which  it  is  desired  the  new  vaginal  floor  shall 


Fig.  299. — Introduction  of  sutures  in  flap-splitting  operation  (Baldy). 

exist ;  this  point  is  usually  that  at  which  the  lower  caruncle  (remnant 
of  the  hymen)  exists,  which  point,  in  addition,  can  be  located  by  the 
existent  scar-tissue.  The  depth  of  the  incisions  tapers  gradually  until 
they  reach  the  highest  point  on  the  labia.  When  completed  the  incisions 
form  the  elliptical  figure  U." 

"  For  Complete  Laceration. — Where  the  sphincter  ani  muscle  is 
involved  in  the  laceration  the  method  of  repair  is  precisely  similar, 
with  the  addition  of  two  small  slits.  They  are  made  by  cutting  down 
each  side  of  the  anus  to  the  ends  of  the  retracted  sphincter  muscle. 


704  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

beginnin<^  the  cuts  at  the  curve  of  the  original  incision.  Their  length 
and  depth  are  variable,  depending  upon  the  position  of  the  retracted 
ends  of  the  sphincter  muscle,  which  must  be  exposed,  so  that  when 
they  are  brought  together  the  two  ends  may  unite.  When  completed 
the  incisions  present  the  appearance  as  shown  in  Fig.  298. 

"  With  the  sides  of  the  wound  well  separated  the  sutures  are  passed 
transversely.  Beginning  at  the  middle  of  the  opening,  the  handled 
needle  is  made  to  pierce  the  skin  about  one-eighth  of  an  inch  from  its 
cut  edge,  is  carried  three-quarters  of  the  way  to  the  bottom  of  the 
wound,  where  it  is  made  to  emerge,  and,  being  reintroduced  at  a  point 
directly  opposite  the  point  of  emergence,  is  carried  under  the  tissues 
of  the  opposite  side  until  it  appears  on  the  skin-surface  at  a  point 
directly  opposite  that  at  which  it  was  first  introduced  (Fig.  299).  The 
eye  of  the  needle  is  now  threaded  with  a  silkworm-gut  suture  and  the 
needle  withdrawn,  dragging  with  it  the  end  of  the  suture.  Several 
similar  sutures  are  passed  above  and  below  the  median  one.  The  top- 
most suture  must  pass  through  the  vaginal  flap  as  it  is  held  up  by  a 
tenaculum ;  the  lower  suture,  if  the  laceration  be  a  complete  one,  must 
include  both  ends  of  the  retracted  sphincter  muscle.  The  correspond- 
ing ends  of  the  suture  are  now  tied,  or,  better,  shotted ;  the  pelvic  floor 
is  lifted  up  toward  the  pubis  by  the  crowding  in  below  of  the  gluteal 
tissues.  The  result  forms  a  very  firm  and  substantial  support  to  the 
outlet,  but  in  no  way  has  any  influence  on  any  injury  done  to  the  vagi- 
nal floor." 

IV.   DISORDERS  OF  MENSTRUATION. 

Amenorrhea. — By  amenorrhea  is  meant  an  absolute  suppression 
of  the  menstrual  secretion.  This  condition  must  not  be  confused  with 
an  obstructed  flow,  as  in  atresia  of  the  vagina. 

Etiology. —  I.  In  acute  diseases,  as  typhoid  fever,  the  menstruations 
cease,  and  reappear  after  convalescence.  In  chronic  diseases,  as  tuber- 
culosis, carcinoma,  Bright's  disease,  leukemia,  anemia,  and  syphilis,  the 
menstrual  flow  becomes  more  and  more  scant,  recurring  at  irregular 
intervals,  and  finally  may  wholly  disappear,  the  result  of  malnutrition 
and  anemia. 

2.  Emotion  from  fright  or  sorrow  may  suddenly  check  the  men- 
strual flow :  we  often  find  amenorrhea  in  the  insane  and  hysterical. 
Changes  in  climate,  mode  of  life,  and  habits  will  often  cause  cessation 
of  the  menstrual  periods.  Long-continued  mental  strain  from  school- 
work  is  a  frequent  cause.  Obesity  and  amenorrhea  are  not  infrequently 
associated. 

Local  causes,  which  include  congenital  anomalies  of  the  uterus  and 
the  appendages,  rendering  them  incapable  of  performing  the  menstrual 
function,  chronic  inflammation  of  the  uterus,  ovaries,  and  tubes,  also 
cysts  and  solid  tumors  of  the  ovaries,  may  cause  amenorrhea,  though 
late  in  their  course.  Pelvic  inflammation  involvdng  the  tubes  and  ovaries, 
when  far  advanced,  rarely  causes  a  partial  or  complete  cessation  of  the 
menses.  Hyperplasia  of  the  uterus  following  pregnancy,  also  prolonged 
lactation,  may  interfere  with  the  menstrual  function. 

"  Catching  cold,"  to  which  amenorrhea  is  often  ascribed,  is  probably 
a  vaso-motor  disturbance. 


DISEASES  AND   INJURIES   OF  FEMALE    GENERATIVE    ORGANS.     705 

Symptoms  and  Diagnosis. — The  symptoms  are  largely  referable  to 
the  causes  of  the  amenorrhea.  Various  nervous  phenomena  may  be 
manifest ;  these  are  referable  to  the  accompanying  anemia  and  hysteria. 
There  may  be  a  cutaneous  eruption,  as  herpes,  erysipelas,  eczema,  and 
acne ;  vicarious  menstruation  may  develop  in  the  form  of  epistaxis, 
hematemesis,  hemoptysis,  hematuria,  subcutaneous  hemorrhage,  and 
bleeding  piles. 

A  full  history  of  the  case  will  often  lead  one  to  the  correct 
diagnosis,  and  should  be  followed  by  a  thorough  physical  examina- 
tion systematically  performed.  If  the  amenorrhea  is  primary,  we  are 
then  led  to  suspect  the  presence  of  some  congenital  anomaly  of  the 
uterus  and  ovaries.  If  there  are  premonitory  menstrual  symptoms, 
but  no  menses,  we  are  then  suspicious  of  some  obstruction  to  the  flow, 
as  atresia  of  the  vagina  or  cervix  or  imperforate  hymen.  If  the 
amenorrhea  is  secondary  and  pregnancy  and  lactation  are  excluded,  we 
seek  for  the  cause  elsewhere  than  in  the  uterus,  tubes,  and  ovaries.  A 
bimanual  examination  is  made  to  detect  the  presence  of  any  pelvic  in- 
flammation or  tumor,  the  size  and  position  of  the  uterus,  and  the  con- 
dition of  the  tubes  and  ovaries.  By  making  a  thorough  examination 
of  the  blood,  urine,  chest,  and  abdomen  causes  least  suspected  may  be 
found. 

Treatment. — The  cause  of  the  amenorrhea  should  not  be  lost  sight 
of,  and  the  treatment  must  be  directed  to  the  removal  of  that  cause. 

The  so-called  emmenagogues  are  of  service  in  certain  individual 
cases,  particularly  in  those  cases  ascribed  to  "  catching  cold  ;"  the  most 
generally  employed  are  manganese  dioxid  and  potassium  permanganate. 

Where  the  condition  is  dependent  upon  impoverished  blood  or 
nerv'ous  depression,  tonics,  alteratives,  and  all  means  of  improving  the 
general  condition  will  be  of  service.  Good  results  from  electricity  are 
claimed. 

Fresh  air,  out-door  exercise,  gymnastics,  a  change  of  occupation, 
climate,  and  scenery,  all  aid  in  re-establishing  the  functional  activity  of 
the  genital  organs.  Acute  suppression  is  best  treated  with  rest  in  bed, 
hot  fomentations,  and  hot  douches. 

Menorrhagia. — The  term  menorrhagia  implies  an  excessive  men- 
strual flow  either  as  to  frequency  of  recurrence,  amount  of  discharge, 
or  its  duration. 

Etiology. —  I.  The  general  eanses  are — acute  fevers,  as  yellow  fever 
and  typhoid  fever  ;  impoverished  blood,  as  in  anemia  and  chlorosis ; 
obstructive  lung-diseases,  as  pneumonia  and  emphysema  ;  cardiac  in- 
sufficiency ;  hepatic  obstruction  from  cirrhosis  of  the  liver ;  diseases  of 
the  spleen  and  kidney ;  abdominal  tumors ;  chronic  constipation, 
cachexia,  hemophilia,  purpura,  scorbutic  plethora,  phosphorus-  and 
arsenic-poisoning,  and  psychical  emotions. 

2.  Local  Causes. — These  include  nearly  the  whole  category  of  pel- 
vic disorders — congestion,  displacements,  inflammations,  polypi  and 
tumors  of  the  uterus,  endometritis,  ovarian  tumors,  pelvic  inflammation, 
retained  products  of  conception,  carcinoma  of  the  cervix,  and  lacerated 
cervix.  Menorrhagia  may  be  caused  reflexly,  in  the  absence  of  any 
lesion,  at  puberty,  from  the  first  coition,  and  during  lactation. 

Diagnosis. — Menorrhagia  must  be  distinguished  from  metrorrhagia, 
45 


7o6  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

which  is  a  flow  of  blood  from  the  uterus  occurring  between  menstrual 
periods ;  these  conditions  frequently  coexist  and  are  dependent  upon 
a  like  cause.  The  diagnosis  is  directed  to  the  recognition  of  the  cause, 
which  in  every  case  must  be  sought  for  by  a  systematic,  thorough 
examination. 

Treatment. — The  cause  determines  the  treatment ;  when  not  found 
the  treatment  must  be  palliative  and  symptomatic.  In  all  cases  the 
patient  is  to  be  placed  in  bed  with  the  hips  elevated,  a  light  diet  given, 
and  the  bowels  kept  freely  open  ;  ice  may  be  applied  to  the  hypo- 
gastric, sacral,  and  lumbar  regions. 

Of  the  internal  remedies  employed,  ergot  stands  at  the  head  of  the 
list ;  tincture  of  opium  may  be  given  per  rectum  or  by  the  stomach  ; 
hamamelis,  belladonna,  tannic  and  gallic  acids,  atropia,  and  digitalis 
are  the  chief  of  the  many  remedies  advocated. 

As  a  temporary  means  of  controlling  a  severe  hemorrhage  the 
uterus  may  be  packed  with  iodoform  gauze,  but  usually  packing  the 
vagina  will  suffice. 

Emmet  has  advised  as  the  last  resort  to  temporarily  stitch  the  cer- 
vical canal.  Prolonged  hot-water  douches,  as  hot  as  can  be  well  borne, 
will  be  of  great  service. 

Where  the  patient  is  profoundly  exhausted  and  anemic  a  stimulant 
should  be  given  ;  the  hypodermic  injection  of  strychnia,  nitro-glycerin, 
and  digitalis  will  be  found  to  be  most  reliable.  Where  general  debility 
ensues,  tonics,  physical  exercise,  and  nourishing  diet  should  be  advised. 
When  the  cause  is  found  it  must  be  removed  if  possible.  As  a  last 
resort  ovariotomy  or  hysterectomy  may  be  advisable. 

Dysmenorrhea. — The  term  d}'smenorrhea  signifies  painful  men- 
struation. In  the  normal  state  the  menstrual  period  is  associated  with 
a  feeling  of  discomfort,  indisposition,  and  slight  pain  at  the  beginning 
of  the  flow%  but  within  normal  limits  the  pain  is  never  intense. 

Dysmenorrhea  is  merely  a  symptom  of  some  underlying  cause,  to 
ascertain  the  exciting  factor  of  which  a  thorough  examination  is 
necessary. 

The  treatment  will  be  directed  to  the  cause. 

A  number  of  varieties  are  recognized.  These  are — i.  Congestive 
or  inflammatory ;  2.  Neuralgic;  3.  Obstructive;  4.  Ovarian;  5.  Mem- 
branous. 

1.  Congestive  dysmenorrhea  is  most  frequently  found  in  multipara, 
and  is  dependent  upon  a  pelvic  congestion  or  a  pelvic  inflammation, 
such  as  chronic  endometritis,  metritis,  and  parametritis  ;  it  is  also  pro- 
duced by  uterine  fibroids  and  polypi.  The  pain  is  caused  by  the  ad- 
ditional congestion  incident  upon  the  menstrual  function,  and  appears 
days  before  the  menstrual  flow,  disappearing  with  the  flow.  Where  a 
pelvic  inflammation  exists  constitutional  symptoms  develop.  These 
are  a  slight  rise  of  temperature,  an  increase  in  pulse-rate,  and  a  feeling 
of  general  depression  and  discomfort. 

2.  Neuralgic  Dysmenorrhea. — In  the  neuralgic  variety  no  pelvic 
lesion  exists  or  there  is  no  uniformity  of  pelvic  disorders.  The  endo- 
metrium is  hyperesthetic,  as  shown  by  the  uterine  sound,  which  when 
introduced  causes  pain  identical  with  the  pain  of  dysmenorrhea.  This 
is  particularly  true  at  the  internal  os. 


DISEASES  AND   INJURIES   OF  FEMALE    GENERA  THE    ORGANS.     707 

Anemia  and  chlorosis  are  predisposing ;  gout,  rheumatism,  syphiHs, 
and  malaria  act  as  exciting  causes.  Neuralgic  dysmenorrhea  is  fre- 
quently associated  with  a  neurotic  temperament,  a  malposition  or  con- 
genital defect  of  the  uterus.  Imperfect  hygienic  surroundings  and  lux- 
uriant living  will  tend  to  bring  about  the  condition.  The  pain  is  not 
constant;  it  may  appear  at  any  time,  and  increases  in  direct  pro- 
portion to  the  flow.  Other  nervous  symptoms  may  be  present,  such 
as  neuralgia,  headache,  twitching,  hysteria,  etc.  In  making  a  diag- 
nosis first  exclude  all  possible  causes  for  other  forms  of  dysmen- 
orrhea. 

3.  Obstructive  dysraenorrhea  is  the  result  of  some  impediment  to 
the  outflow  of  the  menstrual  secretions.  It  may  be  due  to  stenosis  of 
the  cervix,  either  congenital  or  acquired  from  the  use  of  caustics  or  from 
injury ;  to  flexion  and  version  of  the  uterus ;  to  pressure  of  tumors 
upon  the  uterus ;  to  polypi  and  submucous  tumors  of  the  cervix  and 
uterus  which  occlude  the  passage  ;  and  to  atresia  of  the  cervix  and 
vagina  and  imperforate  hymen.  The  characteristic  symptom  is  a  gush 
of  blood,  preceded  and  accompanied  by  pain ;  the  pain  is  paroxysmal 
and  expulsive.  A  physical  examination  will  detect  the  cause  of  the 
obstruction,  and  to  this  the  treatment  is  directed. 

4.  Ovarian  Dysmenorrhea. — In  this  form  the  ovaries  are  enlarged 
and  tender — a  condition  known  as  chronic  ovaritis.  The  pain  precedes 
and  continues  throughout  the  menstrual  period,  gradually  disappearing 
with  the  flow. 

5.  Membranous  dysmenorrhea  exists  in  the  presence  of  chronic 
or  subacute  endometritis.  With  the  flow  of  blood  there  is  shed  a  mem- 
brane {iiccidua  mcnstrnalis)  composed  of  the  menstrual  membrane  in  a 
hyperplastic  state ;  all  the  histological  structures  of  the  membrane  are 
increased  in  size  and  number :  this  may  be  expelled  in  shreds  and  bits 
of  tissue,  or  may  be  cast  off  as  a  complete  triangular  cast  of  the  inter- 
nal surface  of  the  uterus,  with  the  openings  of  the  Fallopian  tubes  and 
internal  os  at  the  three  angles  of  the  triangle.  It  is  distinguished  from 
the  decidua  vera  of  pregnancy  by  the  absence  of  chorionic  villi  and 
decidual  cells. 

Treatment. — The  first  essential  is  to  make  the  diagnosis  of  the  pre- 
disposing and  exciting  causes  and  direct  the  treatment  to  their  removal. 

Palliative  measures  may  be  resorted  to  for  relief  of  suffering  and 
where  no  possible  cause  can  be  found.  The  habitual  use  of  opiates 
cannot  be  too  strongly  condemned,  and  should  only  be  used  as  a  final 
resort ;  they  should  then  be  combined  with  atropin.  In  the  neuralgic 
variety  10  to  20  grains  of  antipyrin  may  be  giv^en  every  hour  for  two 
or  three  doses,  or  nitro-glycerin  in  doses  of  i  minim  of  a  i  per  cent, 
solution  till  there  is  flushing  of  the  face.  Tincture  of  pulsatilla,  TTLv 
three  times  a  day  for  three  days,  often  lessens  or  abolishes  the  pain. 
Other  remedies  are — tincture  of  cannabis  indica,  TTtxx  every  two  or  three 
hours  ;  belladonna,  atropin,  stramonium,  and  hyoscyamus,  given  to  the 
point  of  mydriasis. 

For  the  spasmodic  variety  gelsemium,  musk,  ammonium,  bella- 
donna, and  atropin  are  effectual. 

Bromids  and  chloral  have  been  given  with  good  effect  in  ovarian 
dysmenorrhea. 


yoS  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

Salicylate  of  soda  and  tincture  of  cimicifuga  are  indicated  where 
rheumatism  is  an  underlyint^  factor. 

Mercury  and  potassium  iodid  should  be  given  where  syphilis  exists. 
Where  there  is  congestion,  sitz-baths,  rectal  and  vaginal  douches,  and 
laxatives  should  be  resorted  to. 

Local  treatment  is  of  the  highest  importance,  and  is  to  be  directed 
to  the  existing  lesions. 

IMcmbranous  dysmenorrhea  should  be  treated  by  curetting  and 
packing  with  iodoform  gauze.  All  constitutional  disorders  should  be 
treated — anemia  with  arsenic  and  iron ;  rheumatism  with  salicylates, 
arsenic,  and  iodids;  etc.  This  treatment  should  be  carried  on  through- 
out the  intermenstrual  period.  The  general  condition  must  be  improved 
by  tonics,  exercise,  fresh  air,  good  food,  and  gymnastics. 

V.  MALPOSITIONS  OF  THE  UTERUS. 

Under  the  general  heading  of  Malpositions  will  be  considered 
anteversion,  anteflexion,  retroversion,  retroflexion,  prolapse,  and 
inversion. 

The  normal  position  of  the  uterus  is  not  constant.  The  organ  is 
freely  movable,  and  changes  within  the  normal  limits  occur  as  the 
result  of  a  change  in  the  position  of  the  patient,  the  distention  of  the 
rectum  and  bladder  and  other  pelvic  and  abdominal  viscera.  Ante- 
version  rarely  has  pathological  significance,  and  when  it  does  become 
pathological  it  is  the  result  of  adhesions  drawing  distended  organs  and 
tumors  crowding  the  uterus  forward. 

Anteflexion. — In  anteflexion  the  fundus  of  the  uterus  is  thrown 
forward,  making  a  distinct  angle  of  flexion  at  the  internal  os.  The 
cervix  may  retain  its  normal  relation  to  the  vagina  or  may  be  drawn 
upward  and  backward.  The  posterior  surface  of  the  uterus  lies  upper- 
most, and  on  it  rests  the  weight  of  the  abdominal  viscera ;  thus  the 
condition  is  aggravated.  The  uterine  cavity  is  not  increased  in  depth  ; 
the  cervix  may  be  normal  or  stenotic.  This  position  is  frequently  asso- 
ciated with  an  infantile  uterus.     The  uterus  is  drawn  upward. 

Symptoms. — There  are  no  symptoms  pointing  directly  to  anteflexion, 
and  all  reliance  must  be  placed  upon  the  physical  examination.  The 
patient  may  urinate  frequently  at  night.  Just  before  the  appearance  of 
the  menses  there  are  usually  intermittent  cramping  pains  or  the  pains 
may  be  continuous.  With  the  appearance  of  the  menses  the  pains  be- 
come less  and  disappear  with  the  flow.  The  blood  is  usually  dark  and 
clotted,  and  followed  by  white,  non-irritating  leucorrhea.  Sterility, 
dyspareunia,  and  amenorrhea  are  often  associated  with  anteflexion. 

Bimanual  examination  reveals  the  fundus  thrown  forward  upon  the 
bladder,  the  fundus  being  felt  in  the  anterior  vaginal  vault.  Rectal 
examination  will  demonstrate  the  absence  of  the  uterus  from  its  nor- 
mal position,  and  the  sound  will  reveal  the  depth  and  direction  of  the 
uterine  axis.  Traction  upon  the  cervix  will  facilitate  the  introduction 
of  the  sound  by  straightening  the  canal. 

The  treatment  consists  in  dilating  the  cervical  canal,  thoroughly 
curetting  the  endometrium,  and  packing  the  cava  uteri  with  iodoform 
gauze,  which  is  to  be  left  in  place  for  about  six  days,  then  removed. 


DISEASES  AND   INJURIES   OF  FEMALE    GENERATIVE    ORGANS.     /OQ 

and  nothing  further  done.     Conception  will  frequently  follow  and  the 
painful   menstruations   are  relieved. 

Retro-positions. — Under  this  term  we  include  retroflexion  and 
retroversion  not  due  to  inflammatory  adhesions  or  new  growths. 

Etiology. — Anything  increasing  the  size,  weight,  and  soft  consistency 
of  the  uterus  favors  retro-positions  ;  hence  metritis,  subinvolution,  and 
pregnancy  are  frequent  factors.  Falls  from  a  height  and  increased 
abdominal  pressure,  also  operations,  as  the  removal  of  the  uterine 
adnexa,  which  deprives  the  uterus  of  its  support,  all  operate  in  bring- 
ing on  the  condition. 

Any  lack  of  support  to  the  uterus  from  below  will  directly  bring 
about  the  change  in  position,  and  here  we  have  the  most  common  of 
all  causes — laceration  of  the   perineum. 

Symptoms. — The  universal  complaint  of  women  suffering  from  a 
retro-displaced  uterus  is  pain  in  the  back  and  a  heavy  dragging  sensa- 
tion in  the  pelvis.  Through  pressure  upon  the  rectum  and  the  pain 
occasioned  by  the  movements  of  the  bowels  constipation  results.  The 
bladder  becomes  irritable  through  constant  dragging  upon  it,  and  in 
consequence  there  is  a  frequent  desire  to  urinate  and  a  dribbling  of 
urine  when  the  patient  laughs,  coughs,  or  lifts.  Leukorrhea  is  present, 
and  there  is  pain  radiating  from  the  thighs.  The  menstrual  flow  may 
be  increased  through  the  accompanying  endometritis.  Reflex  symp- 
toms, such  as  hysteria,  occipital  headache,  and  melancholia,  are  •  not 
infrequent. 

Bimanual  examination  will  reveal  a  uterus  which  is  low  in  position. 
The  posterior  lip  of  the  cervix  is  first  palpated  by  the  examining  finger ; 
the  fundus  cannot  be  felt  in  its  normal  position.  No  angle  of  flexion  is 
felt  at  the  internal  os  in  retroversion,  and  the  fundus  uteri  is  felt  to  lie 
against  the  rectum.  In  retroflexion  the  angle  of  flexion  is  felt  in  the 
posterior  cul-de-sac.  The  uterus  is  more  or  less  enlarged  and  tender, 
depending  upon  the  underlying  causes  of  the  displacement.  Rectal 
examination  will  outline  the  position  of  the  fundus,  and,  where  neces- 
sary, the  uterine  sound  will  clearly  demonstrate  the  direction  of  the 
uterine  canal. 

Treatment. — Reposition  of  the  uterus,  providing  the  organ,  is  not 
firmly  adherent,  may  be  effected  by  bimanual  manipulation,  the  knee- 
chest  position,  the  sound,  or  by  instruments  of  support.  The  first  two 
methods  are  often  combined,  and  should  be  persisted  in  faithfully  before 
resorting  to  more  radical  measures.  In  all  cases  see  to  it  that  the 
bladder  and  rectum  are   empty  before  attempting  reposition. 

Bimamial Reposition. — The  clothing  is  loosened  about  the  waist;  the 
semi-prone  position  is  assumed,  with  the  knees  well  flexed.  The  index 
and  middle  fingers  of  the  left  hand  are  introduced  into  the  vagina  behind 
the  cervix.  The  fingers  of  the  right  hand  are  crowded  down  in  the 
direction  of  the  sacrum,  pressure  being  made  by  the  left  hand  imme- 
diately above  the  pubis  (Fig.  300).  The  vaginal  fingers  are  now 
crowded  well  up  in  the  cul-de-sac  of  Douglas,  making  firm  pressure 
upon  the  fundus,  and  at  the  same  time  the  abdominal  fingers  are 
crowded  behind  the  fundus.  In  this  manner  the  uterus  is  brought 
forward  against  the  pubic  arch  until  resistance  is  met.  Now,  holding 
the   body  of  the  uterus  forward,  the  vaginal  index  finger  is  passed  in 


710  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

front  of  the  cervix,  and  the  latter  is  pushed  upward  and  backward, 
thus  producing  an  anteversion.  When  the  patient  is  fleshy  it  will  be 
advisable  to  introduce  the  finger  into  the  rectum. 


Fig.  300. — Reposition  of  retroflexed  uterus  with  patient  in  the  dorsal  position. 

Kiice-cJicst  Reposition. — The  patient  is  placed  in  the  knee-chest 
position ;  air  is  allowed  to  enter  the  vagina  by  means  of  the  Sims 
speculum.     The  cervix  is  drawn  down  by  a  tenaculum,  and  if  the  uterus 


Fig.  301. — Replacement  of  retro-displaced   uterus  by  means  of  the  uterine   repositor,  with 
patient  in  the  knee-chest  position  (Baldy). 

does  not  fall  forward  into  the  natural  position,  pressure  may  be  ap- 
plied to  the  fundus  by  the  finger  or  repositor  (Fig.  301).  The  uterus 
may  be  retained  in  place  by  wool  tampons  placed  in  front  of  the  cervix. 
If  there  are  no  pus-accumulations  in  the  pelvis  and  adhesions  exist,  an 


DISEASES  AND   INJURIES   OF  FEMALE    GENERATIVE    ORGANS.     711 


attempt  may  be  made  to  break  up  these  adhesions  by  exercising 
moderate  force  in  bimanual  reposition  ;  the  attempt  may  be  repeated  at 
intervals  of  two  or  three  days.  A  glycerin  wool  tampon  should  be 
introduced  after  the  operation. 

The  iitcriiw  sound  may  be  resorted  to  in  case  the  above  methods 
fail.  The  operation  consists  in  passing  the  sound  into  the  uterus,  first 
bending  it  in  the  direction  of  the  axis  of  the  canal ;  the  uterus  is  then 
brought  forward  by  making  a  sweep  through  a  half  circle  (Fig.  302). 
Great  caution  must  be  exercised  for  fear  of  injury  to  the  endometrium 
and  puncture  of  the  uterine  wall,  which  has  occurred  in  a  number  of 
instances.  The  operation  should  be  done  with  strict  regard  to  the 
rules  of  surgical  cleanliness,  and  should  be  reserved  as  a  last  resort. 
The   next  step  in  the  treatment  is  to  adopt  means  of  supporting  the 


^^ 


Fig.  302. — Diagnosis  and  reduction  of  retroflexion  by  the  sound. (Courty). 


uterus  in  the  proper  position  and  to  restore  it  to  the  normal  condition 
in  structure  and  function. 

If  endometritis  exists,  the  uterus  should  be  curetted.  A  cotton 
tampon  saturated  with  boroglycerin  or  icthyol-glycerin  is  placed  behind 
the  cervix  in  the  cul-de-sac,  and  the  space  in  front  of  the  cervix  is 
packed  with  a  wool  tampon.  The  glycerin  tampons  are  to  be  removed 
in  six  to  eight  hours,  and  vaginal  douches  of  hot  water  are  given  three 
or  four  times  daily.  The  bowels  are  to  be  kept  regular;  where  the 
perineum  is  ruptured  repair  should  be  made. 

Subsequent  treatment  consists  in  the  repetition  of  the  douches  and 
tamponading  in  the  knee-chest  position.  As  a  rule,  nothing  further 
is  necessary  to  effect  a  cure.  However,  if  the  uterus  does  not  remain 
in  position,  after  all  signs  of  inflammation  have  subsided  a  pessary  may 
be  introduced  and  worn.     Rarely  will   it  be  necessary  to  resort  to  a 


712  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

pessaiy.  The  contraindications  to  its  use  are — i.  The  possibihty^  of  re- 
taining the  uterus  by  the  aid  of  tampons  ;  2.  Existence  of  intlanimation, 
as  salpingitis,  metritis,  urethritis,  vaginitis  ;  3.  Ruptured  perineum  ;  4. 
Bending  of  the  uterus  when  the  pessary  is  in  place;  5.  Pain  produced 
by  the  pessary.  It  will  thus  be  seen  that  the  pessary  is  practically  con- 
fined to  retroflexion  in  the  virgin  state  ;  hence  its  application  is  limited. 
The  pessary  should  be  removed  at  least  once  a  month,  and  daily 
vaginal  douches  should  be  taken. 

When  a  patient  trial  of  tampons  and  pessaries  has  proved  unavailing, 
operative  measures  may  be  resorted  to  with  the  view  of  permanently 
curing  the  retro-displacement.  The  round  ligaments  can  be  shortened 
so  that  the  fundus  uteri  is  held  forward,  or  the  fundus  itself  may  be 
sutured  to  the  abdominal  wall.  For  shortening  the  ligaments  Alex- 
ander's operation  is  generally  employed,  and  consists  in  removing  a 
portion  of  each  round  ligament.  Wylie's  operation  accomplishes  the 
same  purpose  in  a  different  way.  The  abdominal  cavity  is  opened,  the 
fundus  uteri  is  drawn  forward,  each  tube  is  doubled  on  itself,  and  the 
doubled  surfaces  are  sewed  together  and  to  the  peritoneal  covering  of 
the  uterus. 

Alexander' s  Operation. — This  operation  has  a  very  limited  field  of 
usefulness.  Before  it  is  indicated  the  inflammatory  lesions  of  the  pelvic 
organs,  such  as  endometritis,  metritis,  salpingitis,  and  pelvic  inflam- 
mation and  adhesions,  must  be  corrected ;  the  perineum  must  be 
restored ;  in  short,  the  uterus  must  be  in  a  healthy  state,  but  giving 
rise  to  symptoms  purely  referable  to  the  retroflexion,  w^hich  cannot 
be  corrected  by  bimanual  manipulation,  the  knee-chest  position, 
or  the  use  of  tampons,  douches,  and  pessaries.  On  the  day  previous 
to  the  operation  the  uterus  is  put  into  the  normal  position  and  sup-* 
ported  by  tampons  behind  it.  This  precaution,  however,  is  not  neces- 
sary ;  the  uterus  may  be  replaced  at  the  time  of  the  operation  and 
retained  by  tamponading.  The  skin  is  prepared  as  for  abdominal 
section  ;  the  incision  extends  from  the  spine  of  the  pubis,  upward  and 
backward,  over  the  inguinal  canal  for  about  two  inches.  Cutting  care- 
fully down  to  the  external  ring,  the  round  ligament  is  sought  for  with 
blunt  instruments  ;  if  necessary,  the  external  ring  is  incised  and  the 
entire  inguinal  canal  exposed  to  the  internal  ring.  The  round  ligament 
will  be  recognized  by  its  pink,  glistening  appearance.  When  found  it  is 
secured  by  forceps,  and  the  fellow-ligament  sought  for  and  secured  in 
a  similar  manner.  Tension  is  then  made  upon  the  round  ligaments, 
grasping  each  with  the  fingers.  The  excess  in  length  is  cut  off — as  a 
rule,  this  will  amount  to  two  inches  or  more — the  ends  are  united  with 
catgut  sutures,  and  the  incision  is  closed  with  interrupted  sutures. 
The  uterus  is  supported  in  position  by  tampons. 

Hysterorrhaphy. — The  indication  for  this  procedure  is  the  existence 
of  intra-pelvic  lesions,  which  resist  the  treatment  as  advised  under 
Bimanual  Manipulation  and  the  Knee-chest  Reposition.  The  field  of 
operation  is  prepared  as  in  all  abdominal  sections.  The  Trendelenburg 
position  will  be  of  great  advantage.  The  incision  is  short.  With  the 
examining  finger  the  existing  adhesions  are  broken  up,  the  adnexa 
examined,  and,  if  necessary,  they  are  then  removed.  The  uterus  is 
now  brought  forward,  and  a  silk — or,  better  still,  a  silkworm-gut — 


DISEASES  AND   INJURIES   OF  FEMALE    GENERATIVE    ORGANS.     713 

suture  is  passed  through  the  entire  abdominal  wall  on  one  side  ;  then, 
passing  through  the  uterine  wall  at  a  depth  of  about  one-eighth  of  an 
inch,  it  is  again  made  to  penetrate  the  abdominal  wall  opposite  to  the 
point  of  entrance  (Fig.  303).  A  second  suture  is  passed  about  half  an 
inch  higher  up,  and  the  alDdominal  incision  is  then  closed  with  inter- 
rupted sutures  in  the  usual  manner.  The  sutures  passing  through  the 
uterus  should  be  first  secured  and  left  long.  The  remaining  sutures 
are  then  tied,  care  being  taken  to  approximate  the  peritoneal  surfaces. 
It  is  well,  though  not  necessary,  to  gently  scarify  the  peritoneal  surface 
of  the  uterus  to  favor  a  plastic  exudate.  The  two  sutures  passing 
through  the  uterus  are  permitted  to  remain  for  two  or  three  weeks,  and 
the  uterus  is  supported  with  tampons  for  several  weeks  or  months. 
Care  should  be  taken  not  to  suture  the  uterus  too  high  up  or  too  far 


Fig.  303.— Sutures  in  position  in  hysterorrhaphy  (Baldy). 

forward,  for  fear  of  subsequent  dragging  pains  and  irritability  of  the 
bladder. 

Prolapsus  Uteri. — Etiology. — As  a  rule,  prolapsus  occurs  in  mul- 
tiparae,  though  it  may  occur  in  primiparae.  It  is  usually  gradual  in  de- 
velopment, but  may  be  caused  suddenly  from  direct  blows,  falls  from  a 
height,  or  by  lifting.  In  general  the  causes  are  lack  of  support  in  the 
floor  of  the  pelvis  from  ruptured  perineum,  relaxation  of  the  uterine 
ligaments,  increased  weight  of  the  uterus,  and  increased  intra-abdominal 
pressure. 

All  degrees,  from  a  slight  descent  of  the  uterus  to  complete  protru- 
sion from  the  vagina,  are  found.  The  vaginal  walls  are  inverted,  and 
the  uterus  lies  within  the  inverted  vagina  or  may  protrude  more  or  less 
from  the  vulvar  orifice.     This  position  is  usually  associated  with  a  gen- 


714  SrKGICAL    l)/AGXOS/S  AND    TREATMENT. 

eral  chronic  inflammation  of  the  pelvic  organs  and  tissues.  Ulcers  of 
the  cervical  and  vaginal  mucous  membrane  frequently  exist.  Rectocele 
and  cystocele  are  developed.  Dysuria  and  constipation  follow,  and  in 
the  effort  to  evacuate  the  bowel  and  bladder  the  prolapsus  is  aggravated. 

Syniptoiiis. — Occasionally  there  will  be  found  a  complete  prolapse 
of  the  uterus,  yet  the  patient  only  suffers  from  the  inconvenience  of 
the  protruding  bod}-.  The  usual  symptoms  are  backache,  heavy  drag- 
ging sensation  in  the  pelvis,  rectal  or  vesical  tenesmus,  constipation, 
dysuria,  and  pain  radiating  down  the  thighs  and  to  the  sacrum. 

Pressure  upon  the  urethra  may  bring  about  disturbances  in  the 
bladder  and  kidney — namely,  cystitis  and  hydronephrosis.  A  sound 
in  the  urethra  will  pass  in  the  direction  of  the  tumor  for  a  short  dis- 
tance, and  the  end  of  it  can  be  felt  by  the  examining  finger  in  the 
rectum.  Caution  should  be  exercised  in  sounding  the  uterus  lest  preg- 
nancy exist. 

Diagnosis. — Inversion  is  distinguished  by  a  protruding  mass  sur- 
rounded by  the  external  os  and  the  absence  of  the  cervical  canal.  By 
recto-abdominal  examination  the  cupped  upper  extremity  may  be  felt 
and  the  absence  of  the  fundus  uteri  noted.  Submucous  protruding 
fibroids  and  polypi  are  surrounded  by  the  cervix  above,  and  the  fundus 
uteri  is  found  in  the  normal  position. 

Treatment. — The  cause,  if  possible,  must  be  removed.  This  fre- 
quently necessitates  perineorrhaphy.  When  it  is  impossible  to  gain  the 
consent  of  the  patient  to  operate,  or  where  it  is  not  advisable  because 
of  feebleness  and  other  contraindications,  palliative  measures  must  be 
adopted  for  the  support  of  the  uterus  in  its  natural  position.  The  use 
of  pessaries  is  often  disappointing  and  injurious.  The  cup  pessary  is 
the  most  efficient,  and  should  only  be  worn  throughout  the  day. 
Brown's  colpeurynter  is  at  times  serviceable.  It  is  essential  that  the 
uterus,  when  enlarged,  be  reduced  to  its  normal  size.  To  do  this 
curettage  will  afford  a  happy  result  when  the  enlargement  is  due 
to  inflammatory  changes.  Foreign  growths,  as  polypi,  must  be  re- 
moved. The  most  efficient  and  reliable  temporary  means  of  retain- 
ing the  uterus  in  place  is  tamponading  behind  and  about  the  cervix, 
fairly  filling  the  vagina  with  wool  tampons,  the  tampons  being  intro- 
duced in  the  knee-chest  position. 

Perineorrhaphy  and  colpo-perineorrhaphy  having  failed,  hysteror- 
rhaphy  is  the  last  resort,  save  vaginal  hysterectomy  or  amputation  of 
the  cervix  where  the  latter  is  hypertrophied. 

In  acute  prolapse,  where  all  the  symptoms  come  on  suddenly,  the 
patient  is  put  to  bed  in  the  horizontal  position,  the  uterus  being  gently 
replaced  and  held  in  position  by  tampons.  Ice-bags  are  applied  to 
the  abdomen,  and  if  there  are  symptoms  of  internal  hemorrhage,  the 
usual  precautions  are  observed.  For  the  technique  of  plastic  operations 
on  the  perineum  see  chapter  on  Lacerations  of  the  Perineum. 

Inversion  of  the  Uterus. — Inversion  may  be  acute  or  chronic. 
Acute  inversion  properly  belongs  to  the  field  of  obstetrics,  because  of 
the  frequency  with  which  it  follows  labor.  Chronic  inversion  is  almost 
invariably  caused  by  polypi  and  submucous  fibroids.  Multiparse  are 
most  frequently  afflicted,  though  the  condition  is  not  unknown  in  the 
virgin  state. 


DISEASES  AND   EVJCJilES   OE  FEMALE    GENERATIVE    ORGANS.     715 

There  is  more  or  less  bleeding,  sometimes  rendering  the  patient 
anemic  and  exhausted ;  leukorrhea  develops ;  there  is  a  sense  of  ful- 
ness and  bearing-down  in  the  pelv^is.  On  examination  the  inverted 
fundus  is  found  to  occupy  part  or  all  of  the  vagina ;  the  mass  is  red, 
firm,  and  symmetrical.  The  cervix  is  seen  to  closely  constrict  the  mass, 
sometimes  interfering  with  the  circulation  and  causing  sloughing  and 
gangrene.  Death  is  caused  by  exhaustion  from  continuous  loss  of 
blood,  or  from  sepsis  and  peritonitis  where  there  are  sloughing  and 
gangrene  of  the  inverted  uterus. 

Diagnosis. — The  tumor  is  firm,  smooth,  bleeds  readily,  is  constricted 
by  the  os  externum,  and  a  sound  cannot  be  passed  into  the  cavity.  A 
sound  in  the  bladder  and  the  finger  in  the  rectum  can  be  approximated 
and  the  upper  limit  of  the  cervix  felt.  The  body  of  the  uterus  will  be 
absent.  The  minute  openings  of  the  tube  at  the  sides  of  the  base  of 
the  tumor  are  seen.     The  above  signs  will  render  the  diagnosis  complete. 

Treatment. — The  first  method  to  adopt  is  gradual  replacement  by 
gentle,  firm  taxis.  This  is  best  performed  under  anesthesia.  One  hand 
grasps  the  protruding  mass  and  the  other  makes  counter-pressure  over 
the  hypogastrium.  By  repeated  efforts  at  forcing  the  fundus  upward 
the  inversion  may  finally  be  corrected.  If  taxis  fails,  then  make  use 
of  the  colpeurynter,  which,  when  placed  in  the  vagina  and  moderately 
distended,  will  produce  continuous  though  not  severe  pressure.  The 
colpeurynter  should  be  removed  part  of  the  day,  and  gradually  more 
and  more  distended  as  the  inversion  is  corrected.  The  patient  must  be 
confined  to  her  bed,  the  pain  controlled  by  opiates,  and  the  bowels  and 
bladder  kept  free.  When  the  above  methods  fail  after  repeated  efforts, 
vaginal  Jiystcrcctouiy  should  be  the  next  and  last  resort. 

VI.  INFLAMMATION   OF  THE   FEMALE  GENITALS. 

Inflammation  of  the  vulva  (vulvitis)  frequenth-  occurs  in 
infant  as  well  as  in  adult  life.  In  the  infant  highly  acid  urine  and 
oxyurides  from  the  rectum  are  the  exciting  causes.  Later  in  life  the 
acrid,  irritating  discharges  from  septic  and  gonorrheal  vaginitis  and 
endometritis,  from  carcinoma  of  the  cervix,  from  decomposed  urine  in 
cystitis,  and  diabetic  urine  are  found  to  be  the  most  frequent  causes. 
Want  of  cleanliness,  pruritus,  masturbation,  and  friction,  as  from  loco- 
motion in  fleshy  women,  are  occasional  etiological  factors. 

Symptoms  and  Diagnosis. — In  the  acute  stage  there  is  a  sense  of 
fulness  and  pain  on  motion  and  touch ;  pruritus  is  an  almost  constant 
symptom ;  urination  becomes  burning  and  painful ;  the  surface  is 
red  and  slightly  tumefied ;  and  there  is  a  watery  or  mucous  discharge 
from  the  surface.  This  discharge  may  become  muco-purulent  or  puru- 
lent, with  the  development  of  follicular  abscesses ;  one  or  both  of 
the  vulvo-vaginal  glands  may  be  infected  and  an  abscess  develop  or 
the  excretory  ducts  become  occluded,  giving  rise  to  the  formation  of 
retention-cysts.  Ulcers  and  excoriations  of  the  mucous  surface  may 
develop ;  the  sebaceous  and  piliferous  glands  may  become  distended 
with  mucus  or  muco-pus,  causing  them  to  project  from  the  surface  of 
the  labia  and  prepuce  as  prominent  elevations — the  so-called  follicidar 
"vulvitis. 


y\6  SURGICAL   DTAGNOSIS  AND    TREATMENT. 

Treatment  should  be  directed  to  the  renioxal  of  the  cause,  but  cer- 
tain palHative  measures  must  be  adopted  for  the  rehef  of  distressing 
symptoms.  Great  benefit  will  follow  vaginal  douches  of  hot  water  or 
I  to  2  per  cent,  carbolic-acid  solution  or  saturated  boric-acid  solution. 
External  lotions  of  lead-water  and  opium,  hot  applications  of  boric-acid 
solution,  or  2  per  cent,  carbolic  acid  are  useful  to  relieve  the  irritation 
and  burning  sensation.  Carbolic-acid  ointment  is  effective  in  relieving 
pruritus. 

The  infected  follicles  and  abscesses  should  be  incised,  washed  with 
an  antiseptic  solution,  and  dressed  with  sterilized  or  iodoform  gauze. 

Where  the  vulvitis  becomes  chronic,  giving  rise  to  dry,  thickened, 
furrowed  labia,  an  application  of  20  j^er  cent,  siher  nitrate  will  be  of 
service. 

Vaginitis. — Etiology. — The  causes  of  inflammation  of  the  vagina 
are  similar  to  those  enumerated  under  the  discussion  of  Vulvitis,  in 
addition  to  which  may  be  mentioned  any  condition  which  causes  a 
congestion  of  the  mucous  membrane  of  the  vagina,  as  pregnancy  and 
fibroids  of  the  uterus.  The  predisposing  causes  are  constipation,  ane- 
mia, and  general  lowered  vitality.  Any  obstacle  to  the  vaginal  and 
uterine  secretions  whereby  the  irritating  and  decomposed  fluids  are 
retained  in  the  vagina,  as  in  atresia  vaginae  and  imperforate  hymen, 
will  result  in  a  vaginitis.  The  wearing  of  pessaries  may  set  up  a  local 
inflammation.  Here,  as  in  vulvitis,  gonorrhea  is  the  most  frequent  of 
all  the  causes,  and  acrid,  irritating  discharges  from  septic  and  specific 
infection,  together  with  decomposed  and  diabetic  urine,  are  next  in 
point  of  frequency  and  clinical  importance. 

Symptoms  and  Diagnosis. — The  patient  may  complain  of  general 
malaise,  headache,  backache,  and  loss  of  appetite,  though  frequently 
there  are  no  general  disturbances.  There  is  a  sense  of  heaviness  in  the 
pelvis,  a  burning  pain  in  the  vagina,  urination  is  burning  and  frequent, 
an  intense  itching  distresses  the  patient,  locomotion  and  coition  are 
painful,  and  the  vaginal  mucous  membrane  is  very  sensitive  to  touch. 
As  a  rule,  the  inflammation  does  not  involve  the  entire  surface,  but 
attacks  isolated  areas. 

The  inflamed  areas  are  reddened,  tumefied,  and  extremely  sensitive. 
At  first  the  surface  is  dry ;  later  there  appears  a  muco-purulent 
discharge  of  a  white  or  yellowish  appearance.  The  mucous  mem- 
brane may  become  exfoliated  and  the  papillae  infiltrated  and  promi- 
nent, giving  to  the  surface  a  granulated  appearance — granular  vaginitis. 

Small  vesicles  may  develop  on  the  mucous  surface  (vesicular 
vaginitis) ;  the  connective-tissue  spaces  may  become  distended  with 
gas,  giving  rise  to  emphysematous  patches  (emphysematous  vaginitis) ; 
and  rarely  the  denuded  surfaces  may  become  adherent  (adhesive  vagin- 
itis). Small  ulcers  may  form  on  the  site  of  the  vesicles  and  emphy- 
sematous patches,  and  not  rarely  the  mucous  membrane  of  the  urethra 
becomes  reddened  and  tumefied,  discharging  a  yellowish  muco-purulent 
secretion.  Where  this  exists  the  presence  of  gonorrhea  is  highly  prob- 
able. By  pressing  upon  the  urethra  from  behind  forward,  a  drop  of 
pus  will  often  appear  at  the  meatus  ;  if  in  this  pus  the  gonococcus  is 
demon.strated  by  the  aid  of  the  microscope,  the  diagnosis  is  confirmed. 
By  extension  of  the  inflammation  a  cystitis  may  develop  ;  this  may  be 


DISEASES  AND   INJURIES   OF  FEMALE    GENERATIVE    ORGANS.     717 

diagnosticated  by  the  intense  pain  caused  by  pressure  with  the  finger 
against  the  anterior  v^aginal  wall,  and  confirmed  by  an  analysis  of  the 
urine. 

Treatment. — The  cause  must  be  sought  for  and  removed  where 
possible.  As  palliative  measures  the  patient  must  be  at  rest,  not 
necessarily  in  bed,  but  walking  should  be  proscribed,  nor  should 
coition  be  participated  in  until  all  signs  of  inflammation  have  disap- 
peared. The  patient  should  use  hot  vaginal  douches  of  a  saturated 
boric-acid  solution,  a  i  to  2  per  cent,  carbolic-acid  solution,  or  simply 
plain  sterile  hot  water,  repeated  three  times  daily  while  in  the  recumbent 
position  with  the  hips  elevated  upon  the  douche-pan.  Following  the 
douche,  glycerin  tampons  may  be  inserted  or  the  dry  pack  introduced. 
This  consists  of  thoroughly  drying  the  mucous  membrane  with  swabs 
of  cotton  after  the  douche,  then  packing  the  vagina  with  sterilized  or 
medicated  gauze  or  cotton.  When  the  mucous  membrane  is  thoroughly 
dried  the  surface  may  be  dusted  with  a  drying  powder  of  boric  acid, 
bismuth,  aristol,  or  iodoform,  and  the  dry  gauze  or  cotton  tampon  in- 
troduced. In  the  chronic  form  the  mucous  surface  may  be  painted  once 
or  twice  a  week  with  a  2  per  cent,  solution  of  silver  nitrate  or  tincture 
of  the  chlorid  of  iron  and  a  glycerin  tampon  inserted.  Douches  should 
be  given  three  times  a  day.  For  the  relief  of  pain  it  may  be  found 
necessary  to  administer  either  vaginal  or  rectal  suppositories  of  opium. 
Where  pain,  upon  the  introduction  of  the  speculum  or  douche-point, 
is  severe,  the  oleate  of  cocain  should  be  applied.  Lastly,  attention 
should  be  paid  to  the  general  health,  and  tonics  and  alteratives  -given 
where  the  condition  demands. 

Inflammation  of  the  Uterus. — Under  the  general  heading  of 
Inflammation  of  the  Uterus  is  included  cervicitis,  endocervicitis,  metri- 
tris,  and  endometritis.  No  distinct  boundary-line  can  be  drawn  in 
pathology  and  symptomatology  between  these  varieties  of  inflammation 
of  the  uterus,  two,  three,  or  all  four  forms  blending  into  one  another. 

Etiology. — The  bacteriological  factors  in  the  causation  of  inflam- 
mation of  the  uterus  are  in  general  the  pyogenic  and  specific  micro- 
organisms. Most  frequently  present  and  most  virulent  in  its  effects  is 
the  streptococcus  pyogenes.  The  staphylococcus  pyogenes  albus  and 
aureus  are  next  in  point  of  frequency ;  the  streptococcus  erysipelas, 
the  Klebs-Lofler  bacillus,  and  the  bacillus  coli  communis  are  not  in- 
frequently found.  Inflammation  may  rarely  be  ascribed  to  auto- 
infection,  and  to  account  for  such  auto-infection  we  must  assume  the 
presence  of  one  or  more  of  these  varieties  of  germs  in  the  vaginal  or 
cervical  mucous  membrane,  together  with  a  pre-existing  trauma  or 
inflammation  of  the  infected  tissue. 

As  predisposing  factors  may  be  mentioned  congestion  of  the  uterus 
from  suppressed  menstruation,  flexion,  or  the  presence  of  tumors, 
also  retained  secretions  from  atresia  of  the  v^agina  or  cervix,  im- 
perforate hymen,  or  stenosis  of  the  cervix.  Trauma  from  coition 
during  the  menstrual  congestion  and  the  use  of  non-sterilized  sounds 
and  probes  are  too  frequently  the  cause.  By  far  the  most  frequent 
cause  of  infection  arises  during  labor  and  abortion.  The  exanthemata 
and  specific  diseases  may  be  complicated  with  inflammation  of  the 
uterus,  and,  lastly,  the  inflammation  may  extend  from  the  vagina  and 


7l8  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

vulva  ;  and  particularly  is  this  true  of  gonorrheal  vaginitis.  Consti- 
tutional disorders  and  weakness  must  be  considered  as  most  potent 
predisposing;  causes. 

Acute  Endometritis  and  Metritis. — Syviptoms. — There  may 
be  no  general  disturbances,  and  when  present  they  are  of  slight 
consequence,  consisting  of  malaise  with  loss  of  appetite  and  con- 
stipation. There  is  a  sense  of  fulness,  often  associated  with  frequent 
micturition.  When  the  inflammation  is  more  severe  the  above  symp- 
toms become  aggravated ;  there  is  pain  in  the  pelvis,  associated  with 
headache  and  backache. 

Where  the  inflammation  is  the  result  of  septic  infection  during 
parturition  or  the  puerperal  state  the  attack  is  usually  ushered  in  with 
a  chill,  followed  by  a  rapid  rise  of  temperature  from  102°  to  105°  F. 
The  temperature  is  variable,  recurring  at  irregular  intervals.  Where 
the  inflammation  involves  the  tubes,  ovaries,  and  pelvic  tissue,  or  even 
the  abdominal  peritoneum,  the  s}'mptoms  referable  to  these  lesions  are 
added  to  the  above. 

Physical  Signs. — On  palpation  the  uterus  may  be  outlined  as 
somewhat  enlarged  and  tender  to  manipulation.  This  is  best  elicited 
by  bimanual  examination.  Pressure  on  the  cervix  causes  pain.  The 
OS  is  patulous  and  soft  and  may  bleed  easily. 

On  inspection  the  os  externum  is  seen  to  be  congested,  even  turgid; 
the  mucous  surface  may  be  granulated ;  the  cervical  canal  is  filled  with 
a  glassy,  viscid,  opaque  secretion  which  at  times  is  tinged  with  blood. 
Following  abortions  and  labors  the  discharge  may  have  an  offensive 
odor.     The  whole  cervix  is  thickened  and  edematous. 

It  should  be  remembered  that  endometritis  may  exist  in  a  mild  form 
in  the  absence  of  any  of  the  symptoms  enumerated.  There  may  be  a 
suppression  of  the  secretions,  and  this  suppression  is  very  significant 
when  occurring  shortly  after  an  abortion  or  labor.  The  size  and  posi- 
tion of  the  uterus  should  be  noted.  Malaria  may  be  excluded  by  the 
administration  of  quinin.  Cystitis  and  typhoid  fever  should  also  be 
considered  in  making  a  diagno.sis. 

Treatment. — The  patient  should  be  confined  to  bed  during  the  acute 
stage,  the  bowels  kept  freely  open  with  salines  and  enemata ;  hot 
vaginal  douches  of  plain  sterilized  water ;  i  per  cent,  to  2  per  cent, 
solution  of  carbolic  acid  or  bichlorid  solution,  i  :  2000,  should  be  re- 
peated every  four  hours  ;  a  light  diet  should  be  given.  The  uterus 
should  be  irrigated  with  a  mild  antiseptic  solution  once  daily  and  a 
gauze  drain  introduced.  A  glycerin  tampon  should  be  inserted  each 
day,  and  removed  in  from  four  to  six  hours,  followed  by  a  hot  vaginal 
douche.  Where  there  is  severe  pain  a  vaginal  suppository  of  opium 
may  be  inserted. 

W^here  the  inflammation  develops  from  puerperal  infection  no  time 
should  be  lost  in  instituting  active  treatment.  The  vagina  should  be 
sterilized  with  soap  and  water,  followed  by  sterilized  water,  and  lastly 
a  solution  of  i  :  2000  bichlorid.  The  cervix  is  then  dilated  in  the  usual 
manner  if  it  is  not  sufficiently  patulous  to  admit  a  curette.  With  a  sharp 
curette  the  uterus  is  gently  but  thoroughly  scraped ;  all  retained  prod- 
ucts of  conception  and  a  sloughing  endometrium  are  removed ;  a  bi- 
chlorid I  :  2000  douche  is  given,  followed  by  thoroughly  swabbing  the 


DISEASES  AND   INJURIES   OF  FEMALE    GENERATIVE    ORGANS.     719 

interior  of  the  uterus  with  tincture  of  iodin  or  carboHc  acid  and  packing 
it  with  iodoform  gauze ;  lastly,  an  absorbent  sterilized  tampon  is  in- 
serted in  the  vagina  and  the  patient  kept  in  bed  until  all  symptoms 
have  disappeared.  The  gauze  is  removed  from  the  uterus  in  twenty- 
four  to  forty-eight  hours.  If  the  symptoms  of  asepsis  have  disappeared, 
no  further  packing  will  be  necessary,  but  where  the  symptoms  still 
indicate  the  absorption  of  septic  material  a  second  and,  if  necessar}',  a 
third  irrigation  and  packing  of  the  uterus  should  be  done.  Hot  vaginal 
douches  should  be  given  every  four  hours  ;  the  bowels  kept  freely  open 
with  salines  and  enemata ;  if  the  pulse  is  rapid,  weak,  and  irregular, 
stimulation  with  whiskey,  digitalis,  nitro-glycerin,  and  strychnin  should 
be  resorted  to. 

When  absolutely  necessary  pain  is  relieved  by  opiates.  A  strictly 
milk  diet  should  be  enforced  while  the  temperature  is  elevated. 

Bndocervicitis  and  Cervicitis. — Rarely  does  an  acute  inflam- 
mation of  the  cervix  and  cervical  mucous  membrane  remain  local.  The 
tendency  is  to  extend  upward  into  the  body  of  the  uterus  and  endo- 
metrium ;  but  more  frequently  chronic  cervicitis  and  endocervicitis 
remain  localized. 

Syuiptoms  and  Diagnosis. — Where  there  are  no  complications  all 
general  symptoms  are  absent.  Where  hypertrophy  of  the  cervix  exists 
as  a  result  of  the  inflammation,  there  may  be  a  sense  of  weight  in  the 
pelvis.  A  tenacious,  glossy  secretion,  like  the  white  of  an  Qgg,  is  seen 
in  the  cervical  canal ;  this  may  be  blood-stained.  The  os  externum 
is  patulous,  particularly  in  a  multipara  in  whom  the  cervix  is  lace- 
rated. The  cervical  mucous  membrane  is  thickened,  and  bleeds 
easily  when  touched  with  the  probe ;  excoriations  and  erosions 
develop  upon  the  mucous  surface ;  the  mucous  glands  may  become 
occluded,  forming  retention-cysts  which  stand  out  prominently  upon 
the  mucous  membrane,  and  may  go  on  to  the  formation  of  mucous 
polypi.  The  os  externum,  is  surrounded  by  a  congested  surface  which 
may  present  an  excoriated  or  granular  surface.  The  entire  cer\'ix  is 
thickened  to  a  greater  or  less  extent  by  the  tumefaction  and  infiltration 
of  its  muscular  texture. 

Treatment  of  Aente  Endocej'vieitis  and  Cervicitis. — The  cervical  mu- 
cous membrane  should  be  swabbed  with  sterilized  cotton  to  remove  the 
secretions,  and  a  95  per  cent,  carbolic-acid  solution,  tincture  of  iodin, 
or  silver  nitrate  applied  to  the  mucous  surface.  Isolated  polypi  can  be 
excised,  first  injecting  cocain.  Where  there  are  cystic  degeneration  and 
cicatricial  hyperplasia  it  is  well  to  amputate  the  cervix,  as  described 
under  the  Treatment  for  Carcinoma  of  the  Cervix. 

Chronic  Bndometritis  and  Metritis. — Symptoms. — When 
the  inflammation  i.§  mild  and  of  short  duration,  there  may  be  as 
the  only  existing  symptom  a  transient  leukorrhea,  the  secretion 
being  transparent  or  opaque  and  viscid.  If  the  inflammation  involves 
the  deeper  structures  of  the  uterus,  giving  rise  to  infiltration  and  hyper- 
trophy of  the  organ,  there  will  be  a  sense  of  weight  and  bearing-down 
in  the  pelvis,  pain  in  the  lumbo-sacral  region,  and  the  leukorrhea  may 
become  abundant,  thick,  and  of  a  yellowish  color.  Where  the  cervix 
is  lacerated  and  associated  with  erosions  and  excoriations  about  the  os 
externum  the  secretions  are  often  bloodv.     When  the  uterus  is  ante- 


720  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

verted  there  is  a  frequent  desire  to  urinate,  because  of  the  pressure 
upon  the  bladder ;  when  retroverted  there  is  constipation  as  the  result 
of  the  pressure  of  the  uterus  upon  the  rectum.  Menstrual  disorders, 
including  dysmenorrhea,  menorrhagia,  metrorrhagia,  and  amenorrhea, 
are  brought  about  as  the  result  of  the  existing  inflammation.  Sterility- 
may  be  mentioned  as  of  not  infrequent  occurrence.  To  the  above 
s\'mptoms  all  the  manifestations  of  hysteria  may  be  added,  together 
with  neuralgia  of  any  region  of  the  body. 

Physical  Exajiiination. — On  vaginal  examination  the  touch  will  re- 
veal a  cervix  which  is  no  longer  conical,  as  in  the  virgin,  but  one  which 
is  broader  than  it  is  long.  The  os  externum  is  soft  and  patulous  ;  lace- 
rations may  best  be  detected  by  the  touch,  and  in  this  way  also  cysts 
and  polypi  may  be  located.  By  inspection  with  the  aid  of  the  specu- 
lum the  eroded  everted  margin  of  the  os  externum  may  be  seen  and 
existing  lacerations  examined.  Polypi  occasionally  protrude  through 
the  OS  externum,  and  small  cysts  are  not  infrequently  seen  in  the 
inflamed  mucous  surface.  The  cer\'ix  appears  to  have  lost  its  original 
virgin  form  and  to  be  broadened,  and  the  cervical  canal  is  plugged  with 
viscid  mucous  secretion. 

By  bimanual  examination  the  uterus  is  outlined  and  its  position 
determined.  The  organ  is  uniformly  enlarged  and  tender  to  the  touch ; 
as  a  rule,  it  is  retroflexed  or  retroverted  and  freely  movable,  so  that  a 
change  of  position  of  the  patient  will  change  the  position  of  the  uterus 
from  anteversion  to  retroversion. 

The  examination  of  the  uterus  may  be  facilitated  by  producing  trac- 
tion on  the  cervix  with  a  volsellum  forceps  and  by  rectal  palpation. 
By  the  introduction  of  the  sound  the  depth  of  the  uterine  cavity  and 
the  direction  of  the  long  axis  of  the  canal,  together  with  polypi  and 
sensiti\"e  points,  may  be  detected  ;  slight  and  even  troublesome  bleed- 
ing from  the  endometrium  may  be  caused  by  the  introduction  and 
manipulation  of  the  sound. 

Diagnosis. — Chronic  metritis  must  be  differentiated  from  fibroids  of 
the  uterus.  When  the  fibroid  is  subperitoneal  or  intramural,  if  not 
small,  the  examination  will"  determine  the  irregularity  of  outline  of  the 
uterus ;  if  submucous,  the  sound  may  detect  the  irregularity ;  or  if  the 
cervix  is  dilated  and  the  finger  introduced,  the  tumor  can  be  outlined. 
In  fibroids  the  uterus  is  harder  and  more  globular  than  in  metritis. 

Pregnancy  should  not  be  mistaken  for  metritis.  After  the  eighth 
week  of  pregnancy  the  general  and  local  signs  and  symptoms  will 
suffice  for  a  correct  diagnosis,  and  before  the  eighth  week  the  elastic 
ovoid  uterus  may  be  noted.  In  large,  fleshy  women  the  uterus  should 
be  palpated  per  rectum.  In  fibroids  the  cervix  remains  hard,  while  in 
pregnancy  it  is  soft  and  the  os  at  a  late  period  becomes  patulous.  The 
use  of  the  sound  is  never  justifiable. 

Carcinoma  of  the  cervix  and  body  of  the  uterus  in  the  early  stage 
may  give  rise  to  confusion  in  differentiating  from  the  hemorrhagic  form 
of  endometritis,  particularly  that  variety  which  occurs  about  the  time 
of  the  menopause,  the  time  when  carcinoma  is  most  frequent.  In  car- 
cinoma a  profuse  watery  discharge,  tinged  with  blood  and  perhaps 
offensive  to  smell,  is  characteristic.  Where  doubt  exists  the  endome- 
trium should  be  curetted  or  a  wedge-shaped  piece  from  the  cervix  re- 


DISEASES  AND   INJURIES   OF  FEMALE    GENERATIVE    ORGANS.     'J2\- 

moved  and  subjected  to  examination  under  the  microscope.  The  age 
and  family  history  should  be  considered,  and  the  emaciation  and 
cachexia  so  characteristic  of  carcinoma  should  be  noted. 

Treatment. — Where  a  vaginitis  and  a  urethritis  coexist  with  a  chronic 
metritis  and  endometritis,  these  should  be  treated  according  to  the 
principles  already  laid  down.  Where  the  cervix  is  eroded  simply  paint- 
ing with  Churchill's  tincture  of  iodin  may  relieve  the  condition ;  if  not, 
this  process  should  be  preceded  by  curettement.  Cysts  in  the  cervical 
mucous  membrane  should  be  evacuated  either  by  means  of  the  sharp- 
pointed  bistoury  or  cautery.  W'here  the  cervix  is  thickened  and  the 
cervical  canal  filled  with  a  vdscid,  glistening  secretion,  curettement,  fol- 
lowed by  swabbing  the  cervical  mucous  membrane  with  Churchill's 
tincture  of  iodin  or  carbolic  acid,  is  indicated.  It  is  advised  by  a  few 
authorities  in  the  above  condition  to  divide  the  cervix  bilaterally,  thor- 


£ 


Fig.  304. — Amputation  of  the  cervix  with  double  flaps  (Simon) :  A,  sectional  view  showing 
lines  of  incision  for  formation  of  flaps,  and  method  of  suture ;  B,  front  view  of  cervix,  opera- 
tion complete. 


oughly  scrape  away  the  mucous  surface,  and  restore  the  cervix  by  cat- 
gut sutures.  Where  the  cervix  is  greatly  thickened  by  induration  and 
the  mucous  membrane  has  not  become  eroded  or  undergone  follicular 
degeneration,  probably  the  most  satisfactory  operation  is  that  first  ad- 
vised by  Marckwald.  This  is  the  so-called  donblc-fiap  amputation,  or 
conical  excision  of  Simon  (Fig.  304).  This  operation  consists  in  mak- 
ing a  bilateral  incision,  followed  by  taking  a  V-shaped  section  from  the 
anterior  and  posterior  flap  with  the  base  downward  and  the  apex  up- 
ward, thus  removing  the  tissue  intervening  between  the  two  mucous 
surfaces  of  the  cervix :  the  two  mucous  surfaces  are  sutured  with  cat- 
gut and  the  lateral  commissures  united,  thus  preventing  subsequent 
stenosis  from  contraction.  Where  erosions  and  follicular' degeneration 
exist,  this  diseased  tissue  must  be  removed  before  the  lacerated  sur- 
faces are  approximated ;  hence  in  this  condition  the  amputation  of  the 
cervix  as  introduced  by  Schroeder  (Fig.  305)  is  the  operation  par  excel- 

46 


722 


SURGICAL    DIAGNOSIS  AND    TREATMENT. 


Icncc.  This  consists  in  making  bilateral  incision,  then  a  transverse  in- 
cision through  the  internal  mucous  membrane,  and  a  curvilinear  incision 
with  the  con\-exity  downward  through  the  external  mucosa  ;  the  flap  is 


Fig.  305. — Amputation  of  the  cervix  by  one  flap  or  excision  of  the  mucosa  (Schroeder's 
operation):  A,  showing  method  of  placing  the  sutures;  i  and  2  are  those  uniting  the  com- 
missures ;  B,  section  showing  shape  of  incisions  and  {b,  c)  Hne  of  suture ;  C,  shows  position  of 
lips  after  suturing. 

then  excised  from  without  obliquely  upward  and  inward  to  the  point 
of  the  transverse  incision  ;  the  vaginal  and  cervical  mucous  membranes 
are  then  sutured  with  catgut,  and  the  lateral  incisions  united  by  the 


Fig.  306.—^,  diagram  showing  area  of  denudation  and  arrangement  of  sutures  in  Emmet's 
operation ;   B,  appearance  of  cervix  after  sutures  are  tied. 

same  material.  Where  there  is  a  laceration  associated  with  a  catarrhal 
endocervicitis  without  erosions  and  cystic  degeneration  the  Emmet 
operation  is  indicated.     This  consists  in  the  denudation  of  the  edges 


DISEASES  AND  INJURIES   OF  FEMALE    GENERATIVE    ORGANS     723 


of  the  flaps  either  with  a  bistoury  or  scissors,  care  being  taken  to  in- 
clude the  cicatricial  tissue  at  the  angle  of  the  laceration.  The  denuded 
surfaces  are  then  coapted  by  catgut  interrupted  sutures,  beginning  near 
the  upper  angle  of  the  laceration  and  passing  from  without  inward,  in- 
cluding the  vaginal  mucous  membrane  and  two  centimeters  of  the  thick- 
ness of  the  cervix;  then  passing  from  within  outward  at  corresponding 
points  in  the  opposite  flap.  Each  suture  should  be  tied  as  inserted  to 
ensure  perfect  coaptation  and  to  control  hemorrhage  (Fig.  306). 

Chronic  inflammation  of  the  body  of  the  uterus  rarely 
exists  without  accompanying  inflammation  of  the  cervix,  vagina,  or 
Fallopian  tubes,  and  these  lesions  must  not  be  overlooked  in  the  treat- 
ment of  the  disorder.  Curettage  heads  the  list  of  remedial  agents  for 
uterine  inflammation.  The  technique  is  as  follows  :  The  bowels  are  to 
be  freely  opened  with  salines  the  previous  night,  and  an  enema  used  in 
the  morning  of  the  day  of  the  operation  ;  a  vaginal  douche  of  bichlorid 
I  :  2000  should  be  given ;  the  patient  is  anesthetized  and  placed  in  the 
lithotomy  position,  with  the  legs  flexed  upon  the  thighs  and  supported 
either  by  the  Clover  crutch  or  by  assistants.  A  Sims  speculum  is  intro- 
duced ;  the  posterior  lip  of  the  cervix  is  grasped  by  volsellum  forceps 
and  gentle  traction  made,  while  the  canal  is  being  slowly  and  gently 
dilated  by  instruments  of  divulsion  (Fig.  307).  When  the  cervical 
canal  is  sufficiently  dilated  a  sharp  curette  is  introduced  and  the 
entire  uterine  cavity  is  scraped  till 
at  all  points  a  grating  sensation  is 
imparted  to  the  hand  and  can  even 
be  heard,  care  being  taken  to  curette 
the  angles  of  the  fundus.  The  uterus 
is  either  irrigated  with  a  bichlorid 
solution  I  :  2000  or  swabbed  with 
sterile  absorbent  cotton  applied  on  a 
uterine  sound.  Next  the  uterus  is 
swabbed  with  Churchill's  tincture  of 
iodin  and  firmly  packed  with  iodo- 
form gauze.  The  gauze  should  be  in 
one  long,  narrow  strip,  and  should 
be  left  protruding  from  the  cervix, 
where  it  should  remain  for  six  days. 
The  vagina  is  packed  with  absorbent 
cotton,  which  may  be  removed  in 
twenty-four  to  forty-eight  hours,  and 
vaginal  douches  of  bichlorid  i  :  2000 
given  two  to  four  times  daily.  Cu- 
rettage will  be  found  to  be  the  most 
rapid  and  efficient  means  of  de- 
pleting the  uterus.  The  most  happy 
results  are  thus  afforded  in  the 
hemorrhagic  form  of  endometritis, 
and  in  addition  the  following  reme- 
dies have  been  employed :  ergot,  digitalis,  and  hydrastis.  Alarm- 
ing hemorrhage  rarely  occurs  as  the  result  of  curettement,  and  can 
usually  be  controlled  by  tamponading  the  vagina  or  the  uterus  or  by 


Fig.  307. — Instruments  in  position  for  di- 
latation of  the  cervix  uteri  (Baldy). 


J^24  SCKGICAL   n/A GNOSIS  AND    TREATMENT. 

hot-water  irrigation  of  the  latter.  If  tlicse  means  fail,  it  may  be  found 
necessary  to  resort  to  ligation  of  the  uterine  arteries  and  even  to 
vaginal  h)'sterectoniy. 

Gymnastics,  tonics,  and  exercise  will  be  found  valuable  adjuncts  to 
curettement. 

Where  chronic  metritis  is  painful  the  indication  is  to  relieve  the  con- 
gestion, and  this  is  best  done  by  scarifying  the  cervix,  painting  it  with 
iodin,  and  inserting  glycerin  tampons.  When  chronic  metritis  with 
hyperplasia  exists  in  the  absence  of  acute  pelvic  inflammation,  as  a  last 
resort  the  cervix  may  be  amputated.  By  this  method  the  uterus  may 
be  materially  reduced  in  size.  Polk  advises  hysterectomy  where  the 
hemorrhage  continues  after  repeated  curettements,  because  of  the 
strong  probability  of  carcinoma  and  the  comparative  safety  of  vaginal 
hysterectomy.     Prompt,  heroic  action  is  most  imperative  in  such  cases. 

VII.   PELVIC   INFLAMMATION. 

With  the  view  of  simplifying  the  study  of  the  various  inflammatory 
lesions  of  the  female  pelvic  organs  and  tissues  we  will  include  under 
this  heading  salpingitis,  perimetritis,  parametritis,  pelvic  cellulitis,  pelvic 
peritonitis,  and  ovaritis,  because  they  do  not  exist  as  separate  and 
independent  lesions,  but  are  mutually  dependent  upon  the  same  under- 
lying causes,  differing  only  in  the  character  of  the  tissue  involved,  in 
the  extent  and  intensity  of  the  inflammatory  process,  and  in  the  stage 
of  the  inflammation. 

Etiology. — By  far  the  greater  number  of  pelvic  inflammations  arise 
from  septic  infection  of  puerperal  wounds,  as  in  abortions,  premature 
labors,  and  full-term  labors  followed  by  septic  infection.  Next  in  point 
of  frequency  may  be  mentioned  gonorrhea,  which  probably  causes  one- 
third  of  all  cases.  Where  gonorrheal  infection  exists  parturition  may 
excite  an  active  inflammation.  Traumatisms  from  venereal  excess  and 
the  use  of  unclean  instruments,  as  sounds,  tents,  and  specula,  are  pro- 
ductive of  inflammatory  lesions  dependent  either  upon  pre-existing 
pelvic  -inflammation,  as  a  pyosalpinx,  or  upon  the  introduction  of  septic 
material  on  the  instruments.  Menstrual  suppression  is  often  ascribed 
as  a  factor,  and  is  operative  where  there  exists  latent  or  incipient  pelvic 
inflammation.  Where  there  is  no  such  pre-existing  inflammatory 
lesion  suppressed  menstruation  brings  about  a  temporary  pelvic  con- 
gestion rarely  amounting  to  a  permanent  disorder. 

•  Many  attacks  of  pelvic  inflammation  occur  during  the  menstrual 
period,  at  which  time  the  tissues  are  congested,  thus  favoring  the  acute 
exacerbation  of  a  pre-existing  chronic  inflammation.  Lastly,  may  be 
mentioned  pelvic  tumors,  scarlet  fever,  measles,  mumps,  and  extra- 
uterine pregnancy. 

Diagnosis. — Acnic  Catarrhal  Salpingitis. — The  existence  of  catarrhal 
salpingitis  cannot  be  diagnosed  with  certainty  without  direct  inspection 
of  the  tube,  and  even  then  the  microscope  may  be  necessary.  The 
symptoms  are  marked  by  the  coexisting  endometritis  ;  rarely  can  the 
tube  be  palpated,  and  when  palpated  no  perceptible  change  is  detected. 
J.  Bland  Sutton  says :  "  The  leading  signs  of  acute  salpingitis  are  not 
dependent  upon  the  tube  itself,  but  become  most  strikingly  declared 


DISEASES  AND   EXJURIES    OF  FEMALE    GENERATIVE    ORGANS.      725 

when  the  disease  involves  the  peritoneum  in  the  immediate  vicinity  of 
the  tube." 

Chnically,  the  acute  form  of  salpingitis  is  usually  preceded  by  a 
vaginitis  or  leukorrheal  discharge,  when  suddenly  the  patient  complains 
of  pain  and  tenderness  on  pressure  in  the  region  of  one  or  both  iliac 
fossae,  and  on  vaginal  examination  one  or  both  ovaries  are  found  to  be 
somewhat  enlarged  and  tender.  This  inflammation  may  slowly  develop 
and  result  in  chronic  salpingitis,  or  it  may  extend  rapidly  through  the 
Fallopian  tube  to  the  pelvic  and  general  peritoneal  cavity,  and  there 
set  up  a  peritonitis  which  may  result  fatally. 

Chronic  Salpingitis. — Symptoms. — The  symptoms  pointing  to  a 
chronic  salpingitis  are  varied  and  oftentimes  indefinite.  In  the  absence 
of  an  acute  exacerbation  there  is  no  pronounced  effect  upon  the  pulse 
and  temperature.  INIalnutrition  may  result  and  neurasthenia  be  mani- 
fest. The  menstrual  flow  is  usually  prolonged  and  profuse,  and  may 
recur  with  undue  frequency.  A  chronic  salpingitis  associated  with 
amenorrhea  points  to  tuberculosis  (Sutton). 

More  or  less  constant  pain  is  experienced  on  either  one  or  both 
sides  of  the  pelvis.  Unquestionably,  the  pain  is  more  severe  when  the 
lesion  is  on  the  left  side,  because  of  the  passage  of  feces  and  gas  within 
the  sigmoid  flexure.  If  both  sides  are  involved,  sterility  will  almost 
certainly  ensue. 

Defecation  is  painful,  and  in  consequence  of  the  associated  suffering 
the  patient  avoids  movements  of  the  bowel  as  far  as  possible,  and  this  habit 
engenders  constipation.  The  same  may  be  said  of  urination  resulting 
in  irritation  of  the  bladder.  Recurrent  attacks  of  acute  pelvic  inflam- 
mation, particularly  at  the  time  of  the  menstrual  periods,  is  an  almost 
characteristic  occurrence  in  chronic  salpingitis.  When  pus  is  suddenly 
discharged  from  the  uterus,  preceded  by  pain  in  the  iliac  fossa,  and  par- 
ticularly where  the  pressure  in  the  region  of  the  tube  causes  an  increased 
flow  of  pus,  it  is  safe  to  infer  that  the  contents  of  a  pyosalpinx  have  been 
discharged  into  the  cavity  of  the  uterus. 

Diagnosis. — Abdominal  palpation  may  not  reveal  the  existence  of  the 
aflected  tube.  There  will  be  a  sen.se  of  resistance  imparted  by  the  ab- 
dominal muscles  in  the  iliac  fossa  of  the  affected  side,  and  tenderness  is 
universally  elicited.  By  bimanual  examination  the  tube  is  outlined  as  an 
elongated,  thickened,  tortuous  mass,  very  tender  to  manipulation,  and 
as  a  rule  fixed  ;  its  continuity  with  the  uterus  is  discerned,  and  rectal 
touch  may  permit  of  a  more  thorough  examination.  Associated  with 
this  condition  the  uterus  is  often  retroflexed.  Retroflexion  of  the 
uterus  has  been  mistaken  for  salpingitis,  though  it  is  difficult  to  imagine 
such  an  error.  Other  sources  of  error  in  diagnosis  are — i.  Fecal  ac- 
cumulation ;  2.  Movable  kidney ;  3.  Small  uterine  myoma ;  4.  Tumors 
of  the  broad  ligament;   5.  Pelvic  cellulitis. 

Hydrosalpinx. — The  tumor  is  more  frequently  bilateral  than 
in  the  preceding  condition,  and  is  found  in  the  region  of  the  appendages. 
If  no  adhesions  exist,  the  tumor  will  be  freely  movable,  the  walls  thin, 
and  upon  digital  manipulation  fluctuation  will  be  detected.  The  con- 
tents are  usually  clear  and  watery,  but  may  be  stained  a  greenish  color 
by  the  presence  of  cholesterin  ;  still  more  frequently  the  fluid  is  of  a 
chocolate  color.     The  ostium    abdominalis  is  closed    by  inflammatory 


726  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

adhesions,  hence  we  have  to  do  with  an  inflammatory  cyst.  When  not 
greatly  distended  the  tumor  is  elongated  and  tortuous,  and  can  be 
traced  from  the  sides  of  the  pelvis  to  the  uterus  in  the  region  of  the 
appendages.  When  more  distended  the  tumor  is  oval  or  rounded. 
An  anesthetic  will  facilitate  the  examination.  The  uterus  may  or  may 
not  be  freely  movable.  It  is  possible  for  hydrosalpinx  to  exist  without 
giving  rise  to  any  subjective  symptoms.  When  large  the  pressure  upon 
the  surrounding  structures  will  cause  pain.  Pain  may  also  be  excited 
by  a  coexisting  local  peritonitis.  Menstrual  disorders,  and  particularly 
too  frequent  and  profuse  menstruations,  are  almost  invariably  present. 
An  intermittent  discharge  from  the  tubes  into  the  uterus  occasionally 
occurs,  and  is  a  pathognomonic  sign  of  hydrosalpinx,  providing  there  is 
a  simultaneous  decrease  in  the  size  of  the  tumor. 

Differential  Diagnosis. —  i.  Ovarian  and  parovarian  cysts  are  less 
freely  movable,  sustain  no  direct  connection  with  the  uterus,  tend  to 
assume  great  proportions,  and  are  not  of  the  sausage  shape  so  cha- 
racteristic of  a  distended  tube. 

2.  Extra-nterine  pregnancy  is  differentiated  from  hydrosalpinx  by 
the  previous  history,  the  accompanying  signs  and  symptoms,  and  by 
w'atching  the  progress  of  the  growth. 

3.  Hematosalpinx  is  almost  impossible  to  differentiate  from  hydro- 
salpinx. The  history  of  a  previous  pregnancy  and  the  tumor  being 
less  fluctuating,  more  or  less  adherent,  and  having  thickened  walls  are 
features  which  will  aid  in  diagnosis. 

Hematosalpinx. — By  hematosalpinx  we  designate  a  tube  distended 
with  blood  not  due  to  tubal  pregnancy.  Nearly  all  cases  of  so-called 
hematosalpinx  are  pregnancies,  and  upon  careful  examination  of  the 
contents  the  remnants  of  the  fetal  body  will  be  found.  J.  Bland  Sutton 
says  that,  in  his  practice,  a  careful  examination  of  tubes  dilated  and 
containing  blood-clot  reveals  an  embryo,  an  apoplectic  ovum,  or  chori- 
onic villi  in  a  large  majority  of  the  cases  ;  these  should  not  be  included 
as  hematosalpinx.  In  hematosalpinx  the  ostium  abdominalis  is  usually 
closed,  while  in  tubal  pregnancy  and  edema  of  the  tube  the  ostium 
is  usually  free  and  open. 

Pyosalpinx. — Where  the  uterus  and  abdominal  ends  of  the  tube 
are  closed  the  pus  accumulates  within  the  tube,  resulting  in  thinning 
of  the  walls  from  distention,  except  where  they  are  thickened  from  in- 
filtration with  the  inflammatory  exudate.  The  pus  may  escape  from 
either  the  uterine  or  abdominal  ostium,  or  may  rupture  through  the 
walls  of  the  tube.  Preceding  the  escape  of  pus  from  the  tube  inflam- 
matory adhesions  are  usually  formed,  and  by  virtue  of  these  adhesions 
the  pus-infection  is  limited,  giving  rise  to  circumscribed  pelvic  abscesses 
and  preventing  general  infection  of  the  peritoneum  and  its  almost  in- 
evitable result — death.  Where  these  adhesions  do  not  exist  there  is 
great  danger  of  general  suppurative  peritonitis.  Where  adhesions  bind 
the  tube  to  the  vagina,  the  bladder,  the  rectum,  or  bowel,  the  rupture  is 
very  apt  to  take  place  into  these  organs.  In  the  smaller  tubes  the 
uterine  ostium  is  frequently  patent,  permitting  of  a  constant  or  inter- 
mittent leakage. 

The  tube  maybe  straight  with  a  distended  distal  end,  or  convoluted 
and  doubled  upon  itself     When  the  tube  is  adherent  to  the  bowel  the 


DISEASES  AND   INJURIES   OF  FEMALE    GENERATIVE    ORGANS.     727 

pus  assumes  a  fetid  odor,  due  to  the  transfusion  of  gases  from  the  in- 
testinal tract.  The  disease  is  usually  bilateral ;  rarely  is  there  one  tube 
entirely  free  from  infection.  The  pus  varies  greatly  in  its  virulence ;  that 
formed  from  the  action  of  the  staphylococcus  and  streptococcus  infec- 
tion following-  abortions  and  labors  is  the  most  virulent.  Gonorrhea 
and  tuberculosis  are  less  virulent,  but  more  persistent. 

Symptoms. — Following  the  symptoms  of  endometritis,  those  of  pyo- 
salpinx  are  ushered  in  by  an  elevation  of  temperature  which  may  sud- 
denly reach  104°  F.,  preceded  by  a  chill,  but  ordinarily  the  tempera- 
ture remains  about  100°  F.  There  are  increased  tenderness  and  pain  in 
one  or  both  iliac  fossae  ;  the  patient  becomes  restless  ;  creepy  sensations 
are  experienced ;  and  there  is  a  gradual  loss  of  flesh.  Upon  examina- 
tion the  tube  can  be  outlined  and  found  to  be  enlarged,  tender,  and 
adherent ;  when  greatly  enlarged  fluctuation  may  be  detected. 

This  condition  must  be  differentiated  from — 

1.  Extra-uterine  pregnancy,  which  may  be  excluded  by  the  history 
and  by  noting  the  progress  of  the  growth.  Other  signs  and  symptoms 
may  be  similar.  The  uterus  is  enlarged  in  both.  The  stomach-  and 
gland-symptoms  may  be  alike  in  both  cases,  the  discharge  of  the  decid- 
ual membrane  is  not  a  constant  occurrence  in  extra-uterine  pregnancy, 
and  the  menstrual  function  is  not  always  suspended. 

2.  Cystic  tumors  are  distinguished  from  pyosalpinx  by  the  absence 
of  infection,  by  the  thin  wall  and  fluctuation,  and  by  the  absence  of 
adhesions  in  the  majority  of  cases. 

3.  Hematosalpinx  is  usually  unilateral,  pyosalpinx  is  generally  bilat- 
eral ;  the  previous  history  will  be  the  distinguishing  feature  in  the  dif- 
ferential diagnosis. 

4.  Hydrosalpinx  differs  in  the  absence  of  general  symptoms,  in  the 
thin  walls  of  the  sac  and  the  freedom  from  adhesions,  and  in  the  ab- 
sence of  a  history  of  puerperal  or  gonorrheal  infection. 

Pelvic  abscesses  are  not  circumscribed  as  a  rule ;  the  mass  cannot  be 
traced  to  the  uterus  as  in  pyosalpinx,  and  it  may  impart  to  the  examin- 
ing finger  the  sensation  of  a  boggy  mass  filling  more  or  less  of  the 
pelvis. 

Inflammation  of  the  Ovaries. — Acute  Oophoritis. — This  con- 
dition rarely  exists  without  a  previous  inflammation  of  the  tube  and 
uterus,  the  inflammation  being  an  extension  from  the  tube.  When 
ovaritis  exists  independent  of  salpingitis,  it  is  either  tubercular  or  due 
to  septic  infection  conveyed  from  the  uterus  to  the  ovary  by  means  of 
the  lymphatic  vessels.  In  cases  of  septic  infection  following  abortions 
and  labors,  single  or  multiple,  small  abscesses  may  be  formed  in  the 
substance  of  the  ovary,  or  the  entire  ovary  may  be  converted  into  one 
large  pus-cavity  surrounded  by  the  tunica  albuginea ;  adhesions  form 
about  the  ovary ;  the  abscess  may  rupture  into  the  surrounding  tissue, 
and  be  limited  by  the  adhesions  giving  rise  to  the  formation  of  pelvic 
abscesses,  or  more  rarely  the  adhesions  may  not  exist  or  fail  to  limit 
the  pus-infection,  and  as  a  result  pelvic  or  general  peritonitis  occurs 
with  the  almost  inevitable  result — death. 

The  symptoms  differ  only  in  intensity  from  those  of  salpingitis. 
Examination  will  reveal  an  enlarged,  adherent,  very  tender,  and  some- 
times fluctuating  ovary. 


728  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

Chronic  Oophoritis. — This  condition  either  follows  upon  and  con- 
tinues from  an  acute  attack,  or  less  frequently  is  chronic  from  the  be- 
ginning. As  with  the  acute  form,  it  either  exists  singly,  in  w^hich  case 
it  is  usually  of  a  tubercular  origin,  or,  as  is  almost  always  the  case,  it 
follows  upon  a  salpingitis,  which  in  turn  is  preceded  by  endometritis  and 
metritis.  Chronic  ovarian  abscesses  are  usually  the  result  of  acute 
septic  infection.  The  symptoms  differ  from  pyosalpinx  in  no  way  save 
in  intensity.  The  enlarged  adherent  tube  can  be  outlined  by  examina- 
tion ;  large  abscesses  may  be  detected  by  fluctuation,  and  if  the  abscess 
approaches  the  vaginal  or  abdominal  surface,  a  positive  diagnosis  of  the 
presence  of  pus  is  made  by  the  use  of  the  aspirating  needle. 

Pelvic  Peritonitis. — In  this  condition  we  have,  as  a  rule,  a  direct 
extension  from  the  preceding  forms  of  inflammation :  seldom,  if  ever, 
does  it  exist  without  cellulitis;  hence  w^e  do  not  have  independent 
symptoms  of  pelvic  peritonitis.  However,  it  is  to  peritonitis  that  most 
of  the  pelvic  symptoms  are  referable  where  pelvic  inflammation  exists. 
Part  or  all  of  the  pelvic  peritoneum  is  involved  :  the  lymph-exudate 
organizes  and  gives  rise  to  adhesions.  Abscesses  form  in  these  adhe- 
sions. They  have  their  origin  in  the  rupture  or  leakage  of  a  pyosal- 
pinx or  ovarian  abscess,  rarely  in  direct  extension  from  the  uterus, 
vagina,  and  rectum,  following  trauma  and  ulceration.  The  presence  of 
adhesions  may  give  rise  to  the  formation  of  a  hard,  immovable  mass 
which  may  occupy  part  or  all  of  the  pelvis.  Where  a  large  abscess 
exists  fluctuation  may  be  elicited,  but  to  differentiate  this  abscess  from 
that  of  a  pyosalpinx  or  ovarian  abscess  requires  experienced  tactile 
sensation,  and  at  times  will  be  found  impossible.  The  diagnosis  of  the 
presence  of  pus  is  as  near  to  a  diagnosis  as  we  can  expect  to  come. 

Cellulitis. — No  distinction  should  be  made  between  cellulitis  and 
peritonitis  in  the  pelv^is.  It  is  essentially  a  septic  process.  Following 
abortions  and  labors,  the  septic  infection  travels  from  the  uterus  to  the 
pelvic  cellular  tissue  by  way  of  the  lymphatics,  or  indirectly  it  arises 
secondary  to  endometritis  and  salpingitis  plus  peritonitis. 

Lacerations  of  the  cervix  and  the  vagina  may  give  entrance  to  septic 
infection  which  extends  directly  to  the  cellular  tissue. 

Symptoms. — In  the  mild  aseptic  forms  the  condition  may  escape 
notice.  When  it  follows  the  septic  infection  of  the  uterus  after  abor- 
tions and  labors  there  is  increased  pain  and  tenderness  in  one  or  both 
iliac  fossae,  a  slight  or  a  rapid  increase  in  the  temperature  and  pulse- 
rate,  a  sense  of  w^eight  and  fulness  in  the  pelvis,  and  pain  in  the  back. 

The  above-mentioned  symptoms  may  all  be  referable  to  salpingitis, 
but  when  the  pain  and  tenderness  extend  throughout  the  pelvic  cavit}' 
and  the  general  symptoms  become  aggravated,  it  may  be  inferred  that 
the  inflammation  has  extended  to  the  pelvic  peritoneum  and  cellular 
tissue.  Where  the  inflammation  follows  upon  suppressed  menstruation 
the  whole  pelvis  is  involved  and  the  general  symptoms  are  pronounced. 

Physical  Examination. — Vagino-abdominal  and  rectal  examination 
will  reveal  the  condition.  In  the  mild  form  nothing  but  tenderness 
may  be  elicited,  together  with  a  possible  fixation  of  the  uterus,  which 
is  also  painful  on  pressure.  In  the  severer  form  the  pelvis  is  more  or  less 
filled  with  an  indurated,  hard  mass  very  tender  to  the  touch.  The 
uterus  is  pushed  to  one  side,  or  if  the  mass  exist  on  both  sides,  the 


DISEASES  AND   INJURIES   OF  FEMALE    GENERATIVE    ORGANS.     729 

uterus  will  be  elevated  and  pushed  forward ;  if  there  is  a  mass  in  the 
posterior  cul-de-sac,  the  uterine  displacement  will  be  simply  forward. 

Chronic  pelvic  inflammation,  as  a  rule,  follows  acute  attacks 
from  septic  infection  incident  upon  abortions  and  labors ;  next  in  point 
of  frequency  comes  gonorrhea.  The  general  symptoms  are  largely 
referable  to  the  digestive  and  nervous  system  ;  there  are  neurasthenia, 
debility,  increasing  emaciation,  indigestion,  constipation,  and  meteorism  ; 
the  pulse  and  temperature  are  not  affected.  The  usual  symptoms  of 
endometritis,  metritis,  and  salpingitis  are  added  to  the  above.  Pain  in 
one  or  both  sides  of  the  pelvis  is  felt  more  or  less  constantly,  being 
increased  upon  urination,  defecation,  and  during  menstruation.  Coition 
is  painful.  Largely  as  the  result  of  pain  caused  by  the  bowel-move- 
ments and  urination,  the  patient  naturally  delays  in  responding  to  the 
calls  of  nature,  with  the  ultimate  result  of  irritability  of  the  bladder  and 
constipation.  Acute  exacerbations  of  pelvic  inflammation,  especially 
during  the  menstrual  period,  are  quite  characteristic. 

Pain  along  the  course  of  the  sciatic,  obturator,  and  crural  nerv^es 
indicates  pressure  upon  these  nerves,  and  painful  contractions  of  the 
psoas  and  iliac  muscles  are  caused  by  the  pressure  of  the  mass  upon 
them.  The  menstrual  function  is  quite  universally  disordered.  Dys- 
menorrhea, amenorrhea,  menorrhagia,  and  metrorrhagia,  one  or  more, 
are  almost  constant  accompaniments  of  the  affection. 

Physical  examination  will  reveal  a  uterus  enlarged,  fixed  by  adhe- 
sions, usually  retroflexed,  and  painful  to  pressure.  There  will  be 
detected  slight  resistance  or  a  well-marked  mass  filling  part  or  all  of 
the  pelvis  and  crowding  the  uterus  in  the  opposite  direction. 

Pelvic  Abscesses. — The  common  source  of  a  pelvic  abscess  is  a 
pyosalpinx  from  which  the  pus  has  either  leaked  through  the  ostium 
abdominalis  or  has  ruptured  through  the  wall  of  the  tube,  and  has 
become  restricted  and  circumscribed  by  adhesions,  thus  protecting  the 
general  peritoneal  cavity  from  invasion.  The  causes  of  less  frequent 
occurrence  are  ovarian  abscess,  suppurative  peritonitis,  cellulitis, 
hematocele,  extra-uterine  pregnancy,  and  extension  from  neighboring 
organs.  The  abscess  is  prone  to  rupture  into  the  vagina,  rectum,  blad- 
der, or,  if  high  enough,  through  the  abdominal  wall.  The  great  danger 
lies  in  the  possibility  of  rupturing  into  the  general  peritoneal  cavity. 

Symptoms. — The  symptoms  of  pelvic  abscess  follow  upon  those  of 
metritis,  pyosalpinx,  ovarian  abscess,  hematocele,  and  pelvic  inflamma- 
tion, and  are  ushered  in  by  a  marked  effect  upon  the  general  and  local 
condition  of  the  patient,  the  intensity  of  the  symptoms  being  propor- 
tionate to  the  rapidity  of  the  infection  of  the  peritoneum  and  cellular 
tissue  and  the  extent  of  the  area  involved.  The  temperature  may  be 
preceded  by  a  chilly  sensation  or  a  chill,  and  may  rise  suddenly  to  an 
alarming  degree.  The  pulse  is  quickened  and  weakened  in  proportion 
to  the  intensity  of  the  infection,  and  is  the  best  guide  to  the  general 
effect  of  the  local  infection.  Respiration  likewise  becomes  quickened. 
When  sweating  occurs  we  have  a  grave  indication  of  general  infection. 
Associated  with  these  symptoms  are  debility,  emaciation,  anorexia, 
and  constipation. 

The  local  symptoms  pointing  to  an  abscess  are — a  sense  of  fulness 
and  weight  in  the  pelvis,  pressure  upon  the  iliac  and  psoas  muscles, 


730  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

causing  painful  contraction  of  these  muscles,  and  pressure  upon  the 
obturator,  crural,  and  sciatic  nerves,  causing  pain  in  the  area  of  distri- 
bution of  these  nerves ;  there  will  be  irritation  of  the  bladder  and 
rectum  if  the  abscess  presses  upon  these  organs. 

Fluctuation  may  be  elicited  when  the  abscess  approaches  the  ab- 
dominal, rectal,  or  vaginal  surface,  and  at  the  seat  of  fluctuation  pus 
may  be  found  by  aspiration. 

Diagnosis  of  pelvic  inflammation  is,  as  a  rule,  easy,  but  to  detect 
coexisting  conditions  is  often  a  difficult  task. 

Psoas  abscess  is  differentiated  by  the  presence  of  signs  and  symptoms 
of  a  lesion  of  the  spine.  The  frequency  with  which  they  coexist  should 
put  one  on  his  guard. 

Fibroid  tiimors  may  be  excluded  by  the  use  of  the  aspirating  needle 
and  the  uterine  sound,  together  with  the  bistoury. 

Hematocele  is  characterized  by  its  sudden  appearance,  and  a  positive 
diagnosis  may  be  made  only  by  means  of  an  aspirating  needle. 

Appendicitis. — There  is  a  history  of  intestinal  disturbances.  Mc- 
Burney's  tender  point  is  found  in  the  majority  of  cases.  No  direct  con- 
nection can  be  traced  between  the  mass  and  the  uterus,  and  there  is  no 
history  of  uterine  disturbances  at  the  time  of  the  attack.  When  the 
mass  is  small,  it  may  be  possible  to  outline  the  tube  and  ovary  distinct 
from  it ;  rarely  can  the  mass  be  traced  to  the  cecum.  If  the  pus  is 
aspirated  and  fecal  material  found  in  it,  the  diagnosis  is  established, 
but  this  procedure  must  be  strongly  condemned.  A  fecal  odor  is  not 
diagnostic,  because  any  abscess  lying  in  contact  with  the  intestine  will 
absorb  gas  from  the  intestinal  tract. 

Carcinoma. — The  history  of  the  case  and  the  symptoms  and  signs 
pointing  to  the  organ  and  tissue  originally  infected  will  aid  in  the 
diagnosis  ;  the  cancerous  cachexia  and  abdominal  ascites  will  also  aid 
in  the  exclusion  of  other  lesions. 

Fecal  Impaction. — This  condition  should  never  mislead  one ;  cathar- 
sis will  eliminate  the  possibility. 

Prognosis. — In  the  mild  forms  there  may  be  complete  re-establish- 
ment of  function  and  the  disappearance  of  all  pathological  lesions.  The 
graver  forms  tend  to  become  chronic,  and  invalidism  from  adhesions 
and  abscesses  is  the  almost  inevitable  result.  Death  may  occur  from 
peritonitis.  Subsequent  acute  exacerbation  is  the  rule.  Treatment  may 
result  in  a  cure,  and  in  nearly  every  case  will  favorably  modify  the 
condition. 

Treatment  of  Pelvic  Inflatntnation. — Prophylaxis, — This  con- 
sists in  the  treatment  of  vaginitis  and  endometritis  before  the  inflamma- 
tion has  extended  to  the  tubes  and  pelvic  tissue,  in  all  the  means  of 
prevention  of  childbed  fever  and  its  timely  treatment  when  the  infection 
has  already  occurred,  in  strict  cleanliness  during  all  operations  and 
examinations  about  the  genital  tract,  and,  lastly,  in  the  prevention  of 
exposure  during  the  menstrual  period. 

Curative  treatment  maybe  considered  under  the  head  oi palliative 
and  operative. 

Palliative  treatment  in  acute  pelvic  inflammation  may  be  briefly  sum- 
marized as  rest  in  bed  till  all  acute  symptoms  have  passed  away ;  hot 
applications  (preferably  a  hot-water  bag)  to  the  abdomen,  hot  water  or 


DISEASES  AXD   EVJCRIES    OF  FEMALE    GENERATIVE    ORGANS.     73 1 

I  :  5000  bichlorid-of-mercury-solution  douches  of  not  less  than  one  gal- 
lon in  quantity  and  repeated  every  four  hours  during  the  acute  stage, 
and  thereafter  once  or  twice  a  day  for  at  least  six  months ;  pelvic  con- 
gestion will  be  greatly  relieved  by  saline  cathartics.  It  will  be  well  to 
have  two  or  more  free  watery  stools  during  the  first  twenty-four  or 
forty-eight  hours,  and  subsequent  daily  movements  of  the  bowel.  By 
means  of  cathartics  much  of  the  pain  will  be  relieved,  and  only  in  ex- 
treme cases  will  it  be  necessary  to  resort  to  opiates.  Glycerin  tampons 
should  be  inserted  in  the  vagina  daily  during  the  active  stage  of  the 
inflammation.  They  should  be  allowed  to  remain  no  longer  than  eight 
hours ;  then  they  are  to  be  removed  and  a  prolonged  hot  vaginal 
douche  given.  The  diet  should  be  light ;  rest  in  bed  should  not  be 
strictly  enforced  after  the  acute  symptoms  have  disappeared.  The 
existing  endometritis  and  metritis  are  to  be  treated  according  to  the 
principles  suggested  in  their  respective  chapters.  During  the  entire 
inflammatory  stage  sexual  rest  must  be  enjoined,  as  it  is  of  the  highest 
importance  that  all  causes  of  pelvic  congestion  be  avoided.  Scarifica- 
tion of  the  cervix  by  a  number  of  punctures  will  result  in  free  bleeding 
and  may  do  much  in  depleting  the  pelvis.  When  a  chronic  inflamma- 
tion follows  upon  an  acute  attack,  the  hot  douches  should  be  continued 
once  or  twice  daily,  the  bowels  kept  freely  open,  sexual  intercourse 
proscribed,  and  a  moderate  amount  of  exercise  should  be  taken.  Some 
benefit  may  be  derived  from  painting  the  vault  of  the  vagina  with  iodin 
or  ichthyol.  The  application  may  be  followed  by  the  introduction  of  a 
glycerin  tampon.  Pressure-symptoms  from  retroflexion  of  the  uterus 
are  best  relieved  by  the  introduction  of  wool  tampons,  placing  them  in 
the  posterior  cul-de-sac  when  the  patient  is  in  the  knee-chest  position. 
The  tampon  should  be  removed  every  three  to  five  days.  The  tampons 
will  also  serve  the  purpose  of  preventing  sexual  excess.  Absorbent 
cotton  should  not  be  used,  because  of  the  tendency  to  contract  and 
become  very  hard.  Pessaries  should  never  be  used  when  any  inflam- 
mation exists.  General  massage  and  galvanism  are  at  times  beneficial. 
When  pus  exists  it  should  be  evacuated  without  delay. 

We  shall  not  attempt  to  enter  into  a  discussion  of  the  comparative 
merits  of  abdominal  and  vaginal  operations  in  pelvic  inflammation,  but 
shall  simply  present  the  claims  of  either  side  and  briefly  express  our 
preference.  In  favor  of  the  abdominal  route  may  be  argued  the  im- 
proved methods  in  abdominal  surgery  and  the  advantage  gained  by 
bringing  the  field  of  operation  into  view  and  being  able  to  palpate 
clearly  the  pelvic  viscera  and  thus  avoid  injuring  neighboring  struc- 
tures. Against  the  choice  of  the  abdominal  route  may  be  argued — 
First,  that  the  barrier  of  adhesions  which  protects  the  general  peri- 
toneal cavity  from  the  pelvic  inflammation  is  broken  down  ;  second, 
where  drainage  is  indicated  it  will  be  necessary  to  drain  against  gravity ; 
third,  the  increased  liability  of  shock  when  the  peritoneal  cavity  is 
exposed. 

Montgomery  thus  enumerates  the  advantages  of  the  vaginal  route : 

1.  It  permits  us  to  explore,  treat,  and  preserve  organs  which  would 
otherwise  be  sacrificed. 

2.  It  promotes  drainage  from  the  most  dependent  portions  of  the 
pelvis  and  enables  the  large  peritoneum  to  be  protected  by  plastic  barriers. 


JIZ  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

3.  ll  enables  us  to  remove  the  uterus  and  its  appendages  with  less 
danf^er  and  much  more  subsequent  comfort  than  if  the  abdominal 
incision  had  been  practised. 

4.  The  adhesions  which  Nature  lias  provided  to  protect  the  vital 
organs  are  undisturbed,  and  consequently  the  patient  is  less  liable  to 
have  subsequent  obstructive  symptoms. 

5.  Convalescence  is  shorter,  and  the  patient  avoids  such  agonizing 
sequelae  as  abdominal  sinuses,  painful  cicatrix,  weakened  ventrum,  and 
ventral  hernia. 

Against  the  vaginal  route  may  be  argued — i.  Danger  of  vesical  and 
rectal  fistuke  ;  2.  Increased  danger  of  injuring  the  ureter;  3.  Inability 
to  see  the  field  of  operation,  thus  relying  much  upon  the  sense  of  touch. 

Where  the  septic  infection  so  debilitates  the  patient  as  to  lower  her 
resistance  to  shock,  vaginal  drainage  is  indicated.  Where  the  pelvic 
abscess  is  extra-peritoneal,  lying  as  it  often  does  between  the  layers  of 
the  broad  ligament,  vaginal  drainage  should  be  employed.  A  trans- 
verse incision  is  made  at  the  junction  of  the  cervix  and  vaginal  vault; 
then  with  a  blunt-pointed  instrument  the  abscess-cavity  is  opened, 
irrigated,  and  packed  with  iodoform  gauze. 

Vaginal  hysterectomy  has  been  advised  where  both  tubes  are  dis- 
tended with  pus.  The  technique  consists  in  making  an  incision  com- 
pletely around  the  cervix  at  the  junction  with  the  vaginal  mucous 
membrane,  and  a  bilateral  incision  on  either  side  of  the  cervix  parallel 
to  the  posterior  surface  of  the  broad  ligament  about  2  cm.  long.  With 
a  blunt  instrument  the  tissues  are  dissected  up  to  the  peritoneum,  hug- 
ging close  to  the  uterus  ;  the  peritoneum  is  opened  ;  the  finger  is  passed 
over  the  fundus  of  the  uterus  and  carried  along  the  tubes  on  either 
side,  gently  separating  the  adhesions.  The  remaining  portions  of  the 
broad  ligament  are  clamped,  and  the  uterus  removed  by  severing  the 
broad  ligament  close  to  the  uterus.  The  wound  is  closely  inspected  for 
bleeding  points,  and  the  cavity  is  packed  with  iodoform  gauze,  care 
being  taken  to  cover  the  ends  of  the  forceps  with  gauze  to  prevent 
pressure-atrophy.  At  the  end  of  forty-eight  hours  the  forceps  are 
removed,  and  twelve  hours  later  the  gauze,  and  the  wound  irrigated 
daily  until  all  discharge  ceases. 

Abdoviinal  Opcratioji. — The  usual  technique  is  observed  in  opening 
the  peritoneal  cavity.  If  the  omentum  and  intestines  are  found  ad- 
herent to  the  parietal  peritoneum,  the  adhesions  should  be  gently 
separated  with  the  fingers.  If  the  omentum  is  so  adherent  as  to  render 
it  impossible  or  dangerous  to  separate  it  from  the  structures  to  which 
it  is  attached,  it  is  best  to  ligate  and  remove  it  in  sections.  Adhesions 
of  the  structures  should  be  gently  separated  by  the  fingers,  and  the 
separated  surfaces  examined  for  injury.  Immediate  repair  of  the 
injured  bowel  or  bladder  is  imperative.  The  Trendelenburg  position 
greatly  facilitates  the  operation.  The  uterus  is  then  outlined  and 
the  examining  finger  worked  well  down  behind  it ;  then  by  a  careful 
sawing  motion  the  adhesions  are  gently  separated  till  the  tube  and 
ovary  are  freed  on  either  side,  always  beginning  at  the  lowest  point 
and  working  upward.  The  ovary  and  tube  are  then  brought  through 
the  abdominal  incision  ;  a  double  ligature  is  passed  through  the  broad 
ligament  immediately  beneath  the  uterine  end  of  the  tube  ;  the  loop  is 


DISEASES  AND  INJURIES   OF  FEMALE    GENERATIVE    ORGANS.     733 

caught  and  the  staff  is  withdrawn ;  two  Hgatures  are  made  by  cutting 
through  the  loop ;  these  are  so  twisted  that  by  tying  the  broad  liga- 
ment and  half  the  tube  with  one  ligature,  and  the  tube  and  half 
the  broad  ligament  with  the  other,  a  sort  of  figure-of-8  ligature  is 
made.  Care  should  be  taken  not  to  include  the  round  ligament, 
as  it  increases  the  danger  of  slipping.  If  the  tube  is  cut  by  the 
ligature,  part  of  the  uterine  tissue  should  be  included  in  its  grasp. 
The  stump  of  the  tube  should  be  cauterized  by  a  Paquelin  cautery 
or  carbolic  acid.  Care  should  be  taken  to  remove  a  distended  tube 
without  rupturing.  If  pus  escapes,  the  pelvic  cavity  should  be  irri- 
gated and  swabbed  dry  with  sterilized  gauze.  Carefully  inspect  the 
pelvis  for  bleeding  points  before  closing  the  abdominal  cavity.  Drain- 
age with  a  rubber  or  glass  tube  is  employed  where  pus  has  ruptured 
into  the  pelvic  or  abdominal  cavity  or  where  many  adhesions  have  been 
separated ;  also  where  there  is  danger  of  having  injured  the  bladder 
and  bowel.  Close  the  abdominal  wound  as  is  customary  in  abdominal 
surgery.  Here,  as  in  all  surgery,  the  axiom  should  prevail,  "  Save 
what  can  be  saved."  Never  sacrifice  a  healthy  tube  or  ovary.  If  the 
tube  is  diseased  and  the  ovar^^-  healthy,  leave  the  ovary  and  remove  the 
tube.  Do  not  neglect  to  treat  the  endometritis  which  nearly  always 
exists.  The  majority  of  uteri  should  be  curetted  during  convalescence 
from  an  abdominal  section  for  pelvic  inflammation. 

VIII.    TUBERCULOSIS  OF  THE   FEMALE   GENITAL  TRACT. 

Tuberculosis  may  involve  one  or  all  parts  of  the  female  genital  tract: 
the  tubes  are  attacked  most  frequently ;  next  in  point  of  frequency,  in 
the  order  named,  are  the  uterus,  ovaries,  vagina,  and  vulva.  As  a  rule, 
genital  tuberculosis  is  secondary  to  primary'  tuberculosis  of  the  lungs  or 
peritoneum,  less  frequently  of  any  other  portion  of  the  body.  That 
primary  tuberculosis  exists  in  the  female  genitalia  there  can  be  no 
question. 

Vulva. — Tuberculosis  of  the  vulva  may  be  an  expression  of  general 
tuberculosis  or  secondary  to  tuberculosis  elsewhere  in  the  body,  but  the 
vulva  is  more  frequently  the  seat  of  primary  tuberculosis  than  any  por- 
tion of  the  genital  tract,  because  of  the  ease  with  which  abrasions  and 
excoriations  of  the  skin  can  be  infected  with  the  tubercle  bacillus.  The 
typical  lesion  is  an  ulcer  with  slightly  elevated  margins  which  are  ir- 
regular and  sharply  defined.  About  the  margins  are  numerous  miliary 
tubercles.  The  ulcer  is  shallow  ;  the  base  is  studded  w'ith  minute  granu- 
lations and  may  have  a  viscid  secretion.  The  ulcer  extends  very 
slowly  and  shows  a  tendency  to  recur. 

Vagina. — The  vagina  is  usually  infected  by  the  leukorrheal  dis- 
charge of  tubercular  endometritis,  and  hence  it  is  the  upper  posterior 
wall  that  is  most  frequently  involved.  It  is  rarely  primary,  and  may 
arise  by  extension  from  the  bladder  and  rectum,  and  in  this  way 
recto-vaginal  and  vesico-vaginal  fistulse  are  sometimes  formed.  It  begins 
as  small  gray  or  yellowish  tubercles,  which  may  coalesce,  break  down, 
and  form  ulcers. 

Uterus. — Tuberculosis  of  the  uterus  may  be  primary,  but  is  gener- 
ally secondary  to  tuberculosis  in  distant  parts  of  the  body  or  neighbor- 


734  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

ing  structures,  particularly  the  tubes  and  vagina.  The  infection  is  at 
first  limited  to  the  endometrium,  but  later  extends  to  the  deeper  struc- 
tures of  the  uterus.  Beginning  as  a  diffused  miliary  tuberculosis,  it 
later  develops  either  into  a  diffused  caseous  degeneration  of  the  endo- 
metrium or  ulceration  ensues.  The  caseous  debris  may  become  locked 
up  in  the  uterus,  giving  rise  to  pyometra.  Interstitial  hyperplasia  of 
the  uterine  tissue  may  result  from  the  chronic  tubercular  endometritis. 
The  cervix  is  rarely,  if  ever,  the  seat  of  primary  tuberculosis.  As  a 
secondary  lesion  it  becomes  either  studded  with  tubercles  or  ulcerated. 

Tubes. — In  nearly  all  cases  of  tuberculosis  of  the  female  genital 
tract  the  tubes  are  involved.  Undoubtedly,  they  may  be  the  seat  of 
primary  tuberculosis,  but  more  frequently  the  disease  is  an  extension 
from  either  the  uterus  or  the  peritoneum,  and  rarely  exists  without 
tuberculosis  elsewhere  in  the  body,  particularly  the  lungs.  The  patho- 
logical lesions  usually  found  are — miliary  tubercles  scattered  over  the 
mucous  surface ;  diffuse  caseous  degeneration  of  the  mucous  mem- 
brane ;  tubercular  ulcers,  involving  the  mucous  and  submucous  tissues; 
and  chronic  interstitial  hyperplasia  of  the  tube-wall.  The  tube  when 
distended  contains  the  typical  caseous  debris  giving  rise  to  the  so-called 
"  caseous  pus-tube." 

Ovary. — The  ovary  may  be  the  only  portion  of  the  genital  tract 
affected,  but  rarely  does  it  exist  as  a  primary  focus,  being  almost  in- 
variably a  complication  of  phthisis  or  peritonitis. 

Tuberculosis  of  the  female  genital  tract  occurs  at  all  ages  from 
childhood  to  adolescence.  When  in  the  extremes  of  life  it  is  usually 
a  secondary  infection,  while  occurring  in  the  age  of  sexual  activity  it 
may  be  primary  or  secondary. 

Syniptoiis  and  Diagnosis. — When  of  secondary  origin  the  symptoms 
are  usually  marked  by  those  of  the  primary  lesion.  The  condition  in 
the  vulva  and  vagina  is  recognized  by  the  peculiarities  of  the  ulcers 
and  granulations  above  referred  to,  by  the  aid  of  the  microscope,  by 
the  slow  progress  in  the  dev^elopment  of  the  lesions,  by  their  ready 
response  to  treatment,  and  by  their  tendency  to  recur.  The  presence 
of  tuberculosis  elsewhere  in  the  body  is  strongly  suggestive  of  the 
tubercular  character  of  the  lesion.  The  miliary  form  is  to  be  distin- 
guished from  granular  vaginitis  by  its  comparative  rarity,  by  the  asso- 
ciation o{ granular  vaginitis  with  pregnancy  and  gonorrhea,  and  by  the 
aid  of  the  microscope. 

Hard  a7id  soft  chancre  and  sypJnlitic  iilccrs  are  differentiated  by  the 
history,  by  the  microscopic  examination,  and  by  the  effect  of  antis)'ph- 
ilitic  treatment. 

Tuberculosis  of  the  cervix  and  body  of  the  uterus  may  be  confused 
with  carcinoma.  A  microscopic  examination  of  the  product  of  curette- 
ment  or  of  a  small  portion  excised  from  the  cervix,  and  the  inoculation 
of  guinea-pigs  with  the  secretions,  will  determine  the  nature  of  the  lesion. 
The  tubercle  bacillus  may  be  detected  in  the  leukorrheal  discharge  by 
the  same  method  as  pursued  in  the  examination  of  sputum.  Edebohls 
says :  "  The  coexistence  of  a  tubal  tumor  or  tumors  with  plaque-like 
thickenings  of  the  subperitoneal  tissues  points  with  the  greatest  distinct- 
ness to  tuberculosis.  The  tuberculosis  under  these  conditions  may 
fairly  be  assumed  to  be  primary  in  the  tube  or  tubes  if  no  other  deep- 


DISEASES  AND   INJURIES   OF  FEMALE    GENERATIVE    ORGANS.     735 

seated  tumors  can  be  palpated  in  the  abdominal  cavity."  The  follow- 
ing words  from  Paul  Petit  are  appended:  "The  tubercular  nature  of 
endometritis  may  be  absolutely  determined  if  scrapings  of  the  debris 
present  the  following  characteristics  :  interstitial  cells  which  are  necrosed 
or  atrophied  in  a  diffused  manner  or  in  well-defined  lines  ;  giant-cells  in 
greater  or  less  numbers ;  embryonal  nodules  detached  from  the  stroma 
and  apparently  developed  around  the  vessels,  whose  lumina  may  or 
may  not  be  preserved ;  numerous  flexible  and  dilated  glands  lined 
with  epithelial  cells  which  are  either  considerably  elongated  or  have 
undergone  an  epithelioid  transformation.  In  order  to  clear  the  diag- 
nosis we  should  always  perform  an  exploratory  curettement,  which 
will  prevent  confusion  with  carcinoma  of  the  body  of  the  uterus." 

In  tubercular  salpingitis  the  nodular  character  of  the  uterine  end  of 
the  tubes  has  been  held  as  pathognomonic,  but  this  is  not  true.  Rarely, 
on  the  posterior  surface  of  the  uterus  and  broad  ligament  are  found 
little  granulations ;  however,  their  presence  is  so  rarely  detected 
that  little  reliance  is  placed  on  their  discovery.  Salpingitis  in  a  virgin 
prior  to  puberty  is  seldom  anything  other  than  tubercular.  The 
association  of  distended  tubes  with  tubercular  peritonitis  is  suggestive 
of  tubercular  salpingitis. 

Treatment. — Prophylaxis  is  essential.  Cleanliness  in  examinations 
and  operations  upon  the  genitalia  should  always  be  observed.  The 
undoubted  conveyance  of  the  infection  from  the  tubercular  genitals 
of  the  male  should  emphasize  the  importance  of  guarding  against  such 
a  possibility. 

Qtrative. — Ulcers  of  the  vulva  and  vagina  will  readily  respond  to 
treatment  with  the  tincture  of  iodin,  iodoform,  Paquelin  cautery,  or 
excision  with  subsequent  suturing. 

Tubercular  endometritis  demands  a  thorough  curettement,  followed 
by  swabbing  with  the  tincture  of  iodin  and  packing  with  iodoform 
gauze.  If  the  results  are  not  satisfactory,  vaginal  hysterectomy  is 
justifiable.  Tuberculosis  of  the  tubes  and  ovaries  demands  their  removal 
except  in  cases  seriousl)^  complicated  with  tuberculosis  elsewhere.  The 
uterus  may  be  curetted  as  suggested  above,  or  a  total  hysterectomy 
be  done. 


IX.  LACERATION  OF  THE  CERVIX  UTERI. 

The  usual  cause  of  laceration  of  the  cervix  is  parturition.  The 
conditions  favoring  laceration  are — i,  forceps  delivery;  2,  hastening 
the  process  of  labor  by  ergot ;  3,  dystocia  from  maternal  causes,  as 
from  a  relatively  large  presenting  body  or  abnormal  presentation  ;  4, 
diseased  cervix.  The  laceration  may  be  partial  or  complete.  In  partial 
laceration  the  entire  thickness  of  the  cervix  is  not  involved,  while  in 
complete  laceration  the  tissues  are  severed  throughout  their  entire 
thickness,  and  the  rent  extends  to  a  variable  distance. 

Lacerations  may  be — i.  Unilateral,  involving  one  or  the  other  side 
of  the  median  line — more  of  the  left  side  because  of  the  relative  fre- 
quency of  the  left  occipito-anterior  presentation.  2.  Bilateral. — The 
most  frequent  variety  is  a  laceration  on  either  side  of  the  median 
line,  the  one  on  the  left  being,  as  a  rule,  the  more  extensive ;  rarely, 


736  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

the  cervix  is  completely  divided  into  an  anterior  and  posterior  flap.  3. 
Stellate. — This  form  consists  of  three  or  more  lacerations;  it  is  com- 
paratively rare,  and  is  seldom  extensive. 

Nature  rarely  repairs  these  injuries,  but  occasionally  healing  will 
take  place  on  the  vaginal  surface,  leaving  a  gaping  wound  communi- 
cating with  the  cervical  canal. 

As  a  result  of  the  laceration,  involution  of  the  uterus  may  be  inter- 
fered with  ;  endometritis  and  endocervicitis  may  result,  accompanied  by 
a  leukorrheal  discharge ;  retention-cysts  may  develop  in  the  mucous 
membrane  of  the  cervix  from  the  occlusion  of  the  cervical  glands; 
granulations  cover  the  lacerated  surface,  and  connective  tissue  is 
increased,  rendering  the  cervix  markedly  hyperplastic. 

Pelvic  inflammation  is  not  the  direct  result  of  the  laceration,  but  of 
the  accompanying  endometritis,  and  sterility  may,  and  often  does,  result 
from  the  endometritis  and  the  plugging  of  the  cervical  canal  with  mucus. 
Abortions  not  infrequently  arise  from  the  accompanying  endometritic 
lacerated  cervix. 

Ruptured  perineum  and  subinvolution  being  frequent  complications, 
we  often  find  displacements  of  the  uterus. 

Carcinoma  of  the  cervix  often  follows  a  laceration. 

Symptoms  and  Diagnosis. — The  symptoms  are,  as  a  rule,  refer- 
able' to  resulting  complications.  There  is  tenderness  of  the  cervix 
during  coitus  and  on  digital  touch  ;  the  cervix  bleeds  easily  upon 
manipulation  as  a  consequence  of  endometritis.  There  may  be  a 
leukorrheal  discharge ;  pains  and  functional  disturbances  may  be 
excited  by  the  laceration  where  subinvolution  and  displacements  are 
present ;  there  is  also  a  sensation  of  weight  and  bearing-down  in  the 
pelvis,  referable  not  to  the  laceration,  but  to  the  enlarged  and  displaced 
uterus. 

The  diagnosis  is  best  made  by  digital  examination.  If  the  lacera- 
tion is  incomplete,  the  cervi-x  may  be  patulous  to  the  index  finger  to  a 
variable  degree  ;  if  complete,  the  lacerated  surface  is  felt  to  be  rough 
and  granular  or  velvety.  A  linear  cicatrix  may  be  felt,  the  remains  of 
a  previous  laceration  which  has  undergone  partial  or  complete  healing. 
Inspection  by  the  aid  of  the  Sims  or  bivalve  speculum  will  confirm  the 
diagnosis ;  the  lacerated  os  externum  will  appear  eroded,  everted,  and 
granular ;  by  the  aid  of  two  tenacula  the  eroded  everted  surfaces  are 
approximated  and  the  granulated  surface  disappears ;  the  cervical 
glands  will  be  seen  to  be  distended,  giving  the  granular  appearance. 
This  is  the  condition  commonly  known  as  ulcer  of  the  cervix. 

Treatment  may  be  immediate  or  secondar)^ 

hnmcdiate  Treatment. — Where  the  laceration  is  extensive  and 
the  hemorrhage  profuse  the  immediate  operation  may  be  done,  though 
with  great  difficulty  in  recognizing  the  relations  of  the  relaxed  parts. 
Continuous  catgut  sutures  may  be  used  and  the  wound  left  to  Nature. 

Secondary  Operation. — The  most  favorable  time  for  the  repair  of 
the  cervix  is  at  the  end  of  the  puerperium,  when  involution  has  pro- 
gressed to  a  considerable  degree  and  before  the  various  complications 
have  arisen,  as  endometritis,  subinvolution,  cicatrix,  and  hyperplasia  of 
the  cervix.  If  done  at  this  time,  no  cutting  is  necessary  beyond  simply 
freshening  the  raw  surfaces  by  the  curette  and  uniting  them  by  the 


DISEASES  AND   INJURIES   OF  FEMALE    GENERATIVE    ORGANS.     737 

interrupted  suture.  In  the  vast  majority  of  cases  the  laceration  is  not 
recognized  until  late,  when  the  complications  arise  and  an  examination 
is  made.  The  indication  for  the  repair  of  the  cervix  is  in  no  way  gov- 
erned by  the  extent  of  the  laceration.  Some  of  the  most  extensive 
lacerations  have  given  rise  to  little  or  no  inconvenience,  while  a  slight 
and  apparently  insignificant  tear  may  be  productive  of  the  most  pro- 
nounced disturbances,  and  give  the  most  satisfactory  results  when 
treated  by  operation. 

The  presence  of  acute  pelvic  inflammation  or  of  pus  within  the  pel- 
vis would  preclude  the  operation  ;  on  the  other  hand,  chronic  non- 
suppurative inflammation  within  the  pelvis  is  no  contraindication, 
provided  care  be  taken  to  avoid  traction  upon  the  cervix,  which  would 
disturb  the  pelvic  organs.  When  endometritis  is  present,  a  preliminary 
dilating  of  the  cervix  and  curettement  of  the  uterus  are  advisable,  to 
be  immediately  followed  by  the  repair  of  the  cervix. 

A  preliminary  treatment  of  the  granular  surface  may  at  times  be 
necessary ;  this  consists  of  opening  the  retention-cysts.  For  the  opera- 
tion the  patient  is  either  placed  in  the  dorsal  or  Sims  position,  resting 
on  a  Kelly  pad.     If  the  patient  can  endure  the  pain  and  the  laceration 


Fig.  308. — Operation  for  laceration  of  the  cervix  uteri. 

is  not  too  extensive,  no  anesthetic  need  be  given.  A  4  per  cent,  solu- 
tion of  cocain  maybe  injected  into  the  cervix  at  various  points,  and  the 
operation  be  done  with  very  little  pain  ;  it  is  best,  however,  to  have  the 
patient  under  complete  anesthesia. 

The  Sims  speculum  is  introduced  and  the  vagina  irrigated  with 
I  :  2000  bichlorid  solution,  and  then  made  dry  by  mopping  with  sterile 
sponges. 

The  anterior  lip  is  seized  by  a  tenaculum  and  the  lacerated  surface 
denuded  with  scissors  or  a  knife  ;  the  posterior  lip  is  treated  in  a  similar 
manner,  care  being  taken  to  remove  all  the  cicatricial  tissue,  including 
that  at  the  apex  of  the  laceration  (Fig.  308).  Sufficient  cervical  mucous 
membrane  should  be  left  to  form  a  cervical  canal.  The  incision  should 
not  extend  higher  up  than  necessary,  for  fear  of  too  much  tension  on 
the  stitches  when  the  uterus  is  replaced.  Bleeding  may  be  free,  and  is 
controlled  by  sponges,  continuous  warm  irrigation,  forceps,  or  ligature. 

When   the    surfaces    are  denuded  and  the  hemorrhage   controlled, 

the  sutures    are  passed,  beginning  a  little  below  the  upper  angle  on  the 

left  side,  entering  the  vaginal  surface,  and  including  the  entire  thiekness 

of  the  cervix,  passing  out  through  the  cervical  mucous  membrane,  then 

47 


738  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

returning  at  corresponding  points  in  the  opposite  side,  passing  from 
within  outward. 

The  second  stitch  is  taken  in  the  middle  of  the  flap,  and  the  third 
near  the  os  externum,  both  being  placed  in  the  same  way  as  the  first. 
As  a  rule,  three  sutures  will  suffice,  but  a  fourth,  and  even  a  fifth,  may 
be  necessary.  The  ends  of  the  sutures  are  caught  with  a  pair  of  hemo- 
static forceps,  and  the  right  side  is  sutured  in  exactly  the  same  manner, 
except  the  sutures  are  reversed  in  direction.  The  sutures  on  both 
sides  are  tied  from  above  downward.  Superficial  stitches  may  be  used 
to  coapt  the  surface.  The  vagina  is  packed  with  iodoform  gauze.  If 
catgut  is  used,  the  wound  is  not  disturbed ;  if  silkworm  gut  or  silk, 
the  stitches  are  removed  in  seven  to  ten  days.  The  patient  is 
kept  in  bed  for  two  weeks,  though  this  is  not  absolutely  necessary. 
When  one  lip,  usually  the  anterior,  is  much  larger  than  the  other,  it  is 
either  amputated  or  reduced  in  size  by  removing  a  V-shaped  piece 
and  then  approximating  the  surfaces.  In  stellate  lacerations,  where 
one  lip  is  small  it  may  be  excised  and  the  flap  on  either  side  coapted. 
If  the  laceration  is  incomplete,  it  should  be  made  into  a  complete  lace- 
ration by  cutting  entirely  through  the  cervix  and  then  repairing  as  in 
ordinary  complete  laceration. 

X.    FIBROID   TUMORS  OF  THE   UTERUS. 

Fibroid  tumors  of  the  uterus  have  essentially  the  same  histological 
structure  as  the  uterus  itself.  Various  synonyms  have  been  applied,  as 
Myoma,  Hysteroma,  Fibro-myoma,  Fibroid,  and  Fibroid  myoma. 

What  the  exciting  and  essential  causes  may  be  is  not  determined. 
According  to  Bayle,  one-fifth  of  all  women  over  thirty-five  years  of 
age  have  fibroid  tumors  of  the  uterus.  It  is  essentially  a  growth  of 
adult  life,  and  occurs  most  frequently  in  the  African  race. 

Of  the  recognized  varieties,  we  will  consider — i.  Polypoid  or  pedun- 
culated fibroids  ;  2.  Submucous  fibroids  ;  3.  Interstitial  fibroids  ;  4.  Sub- 
peritoneal fibroids :  id)  Pedunculated ;  {b)  Sessile  and  free ;  {c)  Intra- 
ligamentous, pelvic,  and  abdominal. 

I.  Polypoid  or  Pedunculated  Fibroids. — These  growths  lie 
within  the  uterine  cavity,  and  are  connected  with  the  uterine  wall  by  a 
pedicle.  They  are  covered  with  endometrium,  which  becomes  hyper- 
trophied  and  perhaps  gangrenous  and  ulcerated.  During  the  men- 
strual period  the  cervix  becomes  dilated  by  the  protruding  polypus, 
and  this  is  the  most  favorable  time  for  their  detection  by  simple  in- 
spection. At  other  times  it  usually  becomes  necessary  to  dilate  the 
cervix  and  make  a  digital  exploration  of  the  uterine  cavity.  Where 
the  polypus  protrudes  through  the  cervical  canal  into  the  vagina,  a 
digital  examination  will  generally  suffice  to  determine  its  relations  to 
the  surrounding  structures  and  differentiate  it  from  a  polypus  of  the 
cerv'ix. 

Inversion  of  the  uterus  may  be  mistaken  for  a  fibroid  tumor,  and 
especially  when  the  inversion  is  due  to  the  presence  of  a  fibroid ;  but 
the  inverted  uterine  tissue  will  be  found  more  sensitive  than  a  neoplasm. 
The  inverted  uterus  can  be  outlined  by  recto-abdominal  palpation,  and 
the  diagnosis  further  established  by  the  aid  of  the  uterine  sound. 


DISEASES  AND  INJURIES   OF  FEMALE    GENERATIVE    ORGANS.     739 

2.  Submucous  Fibroids. — These  growths  he  immediately  beneath 
the  endometrium  and  project  into  the  uterine  cavity.  The  hypertrophied 
mucous  membrane  covering  them  may  become  gangrenous  and  slough. 
Through  the  expelling  influence  of  the  uterine  contractions  the  tumor 
may  project  more  and  more  into  the  uterine  cavity,  either  giving  rise  to 
the  formation  of  a  polypus  or  extruding  it  entirely  from  the  uterus — 
the  so-called  "  spontaneous  enucleation y 

By  bimanual  examination  the  uterus  will  be  found  to  be  uniformly 
enlarged ;  the  uterine  sound  will  detect  the  presence  of  one  or  more 
rounded  tumors  bulging  into  the  cavity,  and  the  cavity  itself  will  be  found 
to  be  increased  in  depth.  This  condition,  when  associated  with  a 
hemorrhage  more  or  less  profuse  and  continuous,  points  to  the  exist- 
ence of  a  submucous  fibroid.  The  diagnosis  is  best  made  at  the 
time  of  hemorrhage,  when  the  cervix  is  dilated.  It  may  be  necessary 
to  dilate  the  cervix  to  a  greater  degree  in  order  to  permit  of  the  intro- 
duction of  the  examining  finger,  which  should  make  the  diagnosis  with 
absolute  certainty.  The  submucous  fibroid  is  felt  as  a  protruding  body 
having  a  broad  rounded  base ;  the  surface  is  even  and  covered  with 
hypertrophied  mucous  membrane.  Where  the  mucous  membrane  is 
gangrenous  and  sloughing,  and  particularly  where  there  are  cachexia 
and  a  putrid,  offensive  discharge,  the  presence  of  a  carcinoma  may  be 
suspected,  but  the  age,  family  history,  personal  history,  and  the  exami- 
nation of  the  product  of  curettement  should  exclude  all  doubt. 

3.  Interstitial  Fibroids. — The  tumor  lies  imbedded  in  the  uterine 
tissue.  When  it  does  not  project  upon  the  peritoneal  or  mucous  sur- 
face, the  diagnosis  becomes  very  difficult,  and  must  be  based  upon  the 
hemorrhagic  discharge  and  the  increase  in  depth  of  the  uterine  cavity. 
Nothing  short  of  the  discovery  of  the  tumor  will  suffice  for  a  diagnosis. 

Incomplete  abortion  is  excluded  by  the  histor>r  and  the  product  of 
curettement. 

Eaidy  pregnancy  may  be  excluded  by  the  history,  by  the  persist- 
ence of  the  menstrual  flow,  and  by  observing  the  progress  in  develop- 
ment. 

Carcinoma  of  the  uterus  may  be  distinguished  by  the  age,  history, 
fetid  discharge,  cachexia,  and  the  examination  of  the  product  of  cu- 
rettement. 

Diseased  adnexa  may  be  diagnosed  usually  by  a  careful  bimanual 
examination  with  the  patient  under  the  influence  of  an  anesthetic.  The 
uterus  is  not  increased  in  size,  metrorrhagia  does  not  exist,  and  the 
development  is  more  rapid. 

Displacements  of  the  uterus  are  recognized  by  bimanual  examination 
and  the  uterine  sound.  It  is  not  uncommon  to  find  displacement  and 
fibroids  coexisting. 

4.  Subperitoneal  Fibroids. — No  hemorrhage  accompanies  this 
condition,  and  the  uterine  cavity  is  not  enlarged.  By  bimanual,  vagino- 
abdominal, and  rectal  examination  the  tumor  or  tumors  are  outlined 
and  their  location  and  relations  to  surrounding  structures  determined. 
They  may  usually  be  distinguished  from  ovarian  cysts  by  their  density 
and  by  the  absence  of  fluctuation,  yet  fluctuation  is  not  always  elicited 
in  ovarian  cysts,  particularly  fibro-cysts.  A  second  point  in  the  dif- 
ferentiation is  the  rapidity  of  growth  of  ovarian  cysts. 


740 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


Floating  kidney  is  distinguished  by  its  form  and  by  replacing  it  in 
its  natural  position. 

In  the  i)itra-ligai)ic7itous  fibromata  the  tumors  grow  and  wedge 
themselves  between  the  layers  of  the  broad  ligament,  crowding  into 
the  iliac  fossa,\  and  are  closely  connected  with  the  uterus.  They  are 
to  be  differentiated  from  parovarian  cysts,  which  have  no  direct  com- 
munication with  the  uterus  and  which  fluctuate. 

A  tube  distended  zvith  pus,  blood,  or  sej'ous  fi?iid,  when  closely  adhe- 
rent to  the  uterus,  may  give  rise  to  confusion,  but  doubt  may  be  dis- 
pelled by  a  carefully-taken  history  and  by  the  aid  of  the  sound. 
These  tumors   usually  increase  slowly  up  to  the  time  of  the  meno- 


FlG.  309. — Multiple  fibroma  of  uterus  complicated  with  triplet  pregnancy  :  i,  pedunculated 
subserous  fibroid  (myoma),  diameter  6  inches  ;  2,  myoma,  diameter  4^  inches  ;  3,  myoma, 
diameter  4  inches  ;  4,  dilated  cervix  at  seat  of  amputation  (from  a  photograph  in  the  collection 
of  Dr.  Jepson,  Sioux  City). 

pause,  when  retardation  in  their  growth  generally  takes  place.  Inter- 
stitial tumors  are  of  slow  growth.  When  multiple,  they  may  crowd 
upon  each  other  and  interfere  with  their  own  nutrition,  first  making 
a  rapid  increase  in  the  size  of  the  uterus.  Spontaneous  enucleation 
and  expulsion  may  take  place  in  either  the  submucous  or  subserous 
variety ;  gangrenous  degeneration  may  precede  the  expulsion  of  the 
tumor.  When  a  subperitoneal  fibroid  is  expelled  into  the  peritoneal 
cavity,  it  becomes  either  absorbed  or  mummified ;  in  rare  instances  it 
may  suppurate  or  become  calcified.  Death  may  result  from  peritonitis 
or  from  the  anemia  consequent  upon  the  frequent  hemorrhage.  Less 
frequent  causes  of  death  are  malnutrition  from  pressure,  uremia,  septi- 
cemia, and  heart-complications. 


DISEASES  AND   INJURIES   OF  FEMAIE    GENERATIVE    ORGANS.     74 1 

Pregnancy  coexisting  with  fibroid  tumors  presents  a  very  serious 
complication  and  renders  diagnosis  difficult.  By  a  strange  coincidence 
these  tumors  grow  with  increased  rapidity  during  gestation.  In  Fig. 
309  are  represented  the  uterus  pregnant  with  triplets  and  numerous 
fibroids,  twelve  of  which  measured  an  inch  and  more  in  diameter. 
Hysterectomy  at  the  third  month  was  followed  by  recovery.  The 
triplets  contained  in  the  uterus  are  represented  in  Fig.  310.  When  the 
tumors  are  subserous,  and  especially  if  pedunculated,  they  can  some- 
times be  pushed  upward  out  of  the  true  pelvis  or  they  spontaneously 
take  this  position,  and  thus  interfere  with  natural  labor  to  only  a  slight 
extent.     If  serious   interference  with   delivery  is  inevitable,  operative 


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Fig.  310. — Triplets  removed  with  uterus  and  fibroid  tumors  (from  a  photograph  in  the 
collection  of  Dr.  Jepson,  Sioux  City). 

procedures  must  be  considered  with  the  view  of  saving,  if  possible, 
both  mother  and  child.  Cesarian  section,  immediately  followed  by 
removal  of  the  tumor,  is  in  many  cases  the  operation  of  choice.  In 
others  Porro's  operation  is  the  most  suitable,  especially  if  the  tumors 
are  confined  to  the  lower  portions  of  the  uterus. 

Treatniejit. — Alterative  treatment  has  no  remedial  effect,  and  should 
be  condemned  as  irrational  and  injurious  to  the  patient. 

Ergot  in  carefully  selected  cases  is  of  service  in  controlling  hemor- 
rhage, in  stimulating  uterine  contractions,  thus  aiding  in  the  expulsion 
of  polypoid  and  submucous  fibroids,  less  frequently  interstitial  fibroids. 
It  may  serve  to  tide  the  patient  over  to  the  menopause,  and  sometimes 
promotes  atrophy  of  interstitial  and  subserous  growths. 


742  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

Curettage,  followed  by  uterine  tamponade,  will  check  the  hemor- 
rhage for  a  considerable  time  and  will  retard  the  growth  of  the  tumor. 
By  this  means  time  may  be  gained  and  the  patient  sustained  till  the 
menopause  brings  about  retrogressive  processes. 

Electricity  tends  to  contract  the  uterus,  to  lessen  hemorrhage,  and 
to  decrease  the  size  of  submucous  and  interstitial  fibroids.  The 
intra-uterine  positive  electrode  causes  atrophy,  but  only  affects  the 
immediate  vicinity  which  it  touches.  The  negative  electrode  liquefies 
the  tumor  superficially.  Superitoneal  tumors  are  but  little  affected. 
The  use  and  abuse  of  electricity  are  responsible  for  the  development 
of  firm  adhesions  which  seriously  complicate  subsequent  operative 
procedures. 

Surgical  Treatment. —  i.  Removal  of  the  uterine  appendages  will 
bring  about  the  usual  changes  of  the  menopause,  and  has  been  advo- 
cated for  all  varieties  of  uterine  fibroids.  Small  interstitial  tumors  are 
markedly  affected,  but  the  operation  has  very  little  influence,  if  any, 
upon  large  tumors.  The  best  results  are  obtained  in  medium-sized 
hard  fibroids  where  hemorrhage  is  severe. 

2.  Ligation  of  tJie  Uterine  Arteries. — The  technique  consists  in  pre- 
paring the  vagina  as  in  all  vaginal  operations.  A  transverse  incision  is 
made  in  the  cul-de-sac  of  Douglas.  The  finger  is  introduced  into  the 
incision  and  the  uterine  artery  located  ;  a  strong  ligature  is  then  passed 
through  the  lower  portion  of  the  broad  ligament  above  the  uterine 
artery  and  tightly  tied.  This  method  is  of  no  service  in  large  tumors 
or  in  the  subserous  variety. 

3.  Morcellation. — In  submucous  tumors  or  in  the  interstitial  variety 
which  has  been  forced  to  protrude  into  the  cavity  of  the  uterus,  com- 
plete enucleation  should  be  done  if  the  size  of  the  growth  is  sufficient 
to  permit  of  its  extraction  through  the  dilated  or  incised  cervix.  If  the 
tumor  cannot  be  extracted  en  masse,  the  cervix  should  be  dilated  to  the 
extreme  degree,  and,  if  this  does  not  suffice,  lateral  incisions  are  made 
in  the  cervix.  Much  advantage  is  gained  by  administering  ergot  for 
some  days  prior  to  the  removal  of  the  growth.  By  this  means  the 
cervix  will  be  more  efficiently  dilated  by  the  protruding  mass.  The 
tumor  is  grasped  with  a  volsellum  forceps  and  traction  made.  With 
the  knife  or  scissors  a  section  is  taken  from  the  tumor,  and  this  process 
is  continued  until  the  entire  growth  is  removed.  Hemorrhage  is  con- 
trolled by  packing  with  iodoform  gauze. 

4.  Vaginal  hysterectomy  is  indicated  where  enucleation  and  morcel- 
lation cannot  be  performed  and  hemorrhage  is  severe.  The  tumor  must 
not  exceed,  in  size,  the  fetal  head.  The  technique  will  be  described 
under  Vaginal   Hysterectomy  for  Carcinoma  of  the  Cervix. 

5.  Myomectomy  is  indicated  in  subserous  growths  and  in  interstitial 
tumors  where  the  uterine  cavity  is  not  entered.  The  abdominal  cavity 
is  opened  in  the  usual  manner,  the  tumor  is  delivered  through  the  ab- 
dominal incision,  the  capsule  is  incised,  and  the  growth  enucleated.  The 
wound  is  then  closed  with  sutures.  The  abdominal  wound  is  closed 
without  drainage  (Fig.   311)- 

6.  Abdominal  Hysterectomy. — The  incision  should  be  made  large 
enough  to  deliver  the  tumor.  Adhesions  when  existing  are  broken  by 
the  fing-er.     The  broad  ligaments  are  tied  off  on  each  side — two  and 


DISEASES  AND   INJURIES   OF  FEMALE    GENERATIVE    ORGANS.     743 

possibly  three  ligatures  will  be  required  for  each  broad  ligament ;  the 
last  should  be  made  to  include  the  uterine  artery,  and  the  first  should 


Fig.  311. — Subperitoneal  nodular  fibroid  tumor  of  the  uterus  (Baldy). 

include  the  ovarian  artery  (Fig.  312).     The  broad  ligament  should  be 
severed  close  to  the  uterus  as  far  as  the  reflection  of  the  peritoneum  to 


Fig.  312. — Method  of  removal  of  a  subserous  uterine  fibroid  :  stitches  in  place  ready  for  tving 

(Baldy). 

the  bladder.  A  circular  incision  through  the  peritoneum  is  then  made 
at  this  point,  passing  completely  around  the  cervix.  A  V-shaped 
wedge  with  the  base  upward  is  taken .  from  the  cervix  and  the  mass 


744 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


removed.  The  stump  of  the  cervix  is  closed  by  buried  catgut  sutures, 
and  the  peritoneal  cuff  stitched  over  the  stump  by  separate  interrupted 
or  continuous  sutures  ;  thus  the  stump  becomes  extra-peritoneal.  The 
Trendelenburg  position  is  almost  indispensable.  The  patient  is  slowly 
lowered  to  the  horizontal  position  before  closing  the  abdominal  cavity, 
and  all  bleeding  points  are  controlled.  If  no  great  oozing  occurs  from 
breaking  up  adhesions  and  pus  does  not  escape  into  the  peritoneal 
cavit\-,  the  abdomen  is  closed  without  drainagfe. 


Fig.  313. — Supravaginal    amputation  of  the  uterus :  A,  first  step,  position  of  second  ligature 
shown ;  B,  cervix  amputated  by  wedge-shaped  incision  (Baldy). 


Fig.  314. — Supravaginal  amputation  of  the  uterus :  A,  cervical  canal  being  closed  by  su- 
tures which  are  buried  by  subsequent  sutures  ;  B,  peritoneal  edges  of  the  stump  in  process  of 
being  whipped  together,  the  lower  stump  being  buried  under  the  peritoneum  (Baldy). 

The  operation  of  supravaginal  hysterectomy,  as  described  by  Dr. 
Baer,  is  as  follow^s  : 

"After  the  required  abdominal  incision  is  made  all  existing  adhe- 
sions of  omentum,  intestines,  etc.  are  separated  in  the  usual  way,  and 
the  tumor  lifted  out  of  the  abdominal  cavity.  If  the  incision  has  been 
an  unusually  lengthy  one,  several  sutures  are  then  placed  at  its  upper 
end  for  the  better  protection  of  the  intestines.  The  patient  may  now 
be  elevated  to  the  Trendelenburg  posture  if  deemed  best,  and  the  parts 
thoroughly  studied,  so  that  a  clear  idea  as  to  the  character  and  loca- 
tion of  the  tumors  and  pedicle  may  be  obtained  before  the  ligation  and 
separation  are  begun.  The  first  step  in  the  operation  is  the  passing  of 
a  sincjle  silk  lia;ature  through  the  broad  ligament  near  the  cervix.    This 


DISEASES  AND   INJURIES   OF  FEMALE    GENERATIVE    ORGANS.     745 

ligature  is  again  made  to  transfix  the  broad  ligament  near  the  outer 
edge,  to  prevent  slipping ;  it  is  then  tied.  A  stout  pedicle-forceps  is 
next  placed  under  the  Fallopian  tube  and  ovary  and  made  to  grasp  the 
broad  ligament  for  the  purpose  of  preventing  reflux  from  the  uterus 
(Figs.  313,  314).  The  ligament  is  now  severed  just  below  the  forceps, 
the  incision  being  carried  close  to  the  tissues  of  the  tumor.  If  deemed 
necessary  another  ligature  is  now  passed  through  the  broad  ligament 
farther  down  along  the  side  of  the  cervix.  This  ligation  and  cutting 
are  now  repeated  on  the  opposite  side.  The  knife  is  then  run  lightly 
around  the  tumor  an  inch  or  two  above  the  peritoneal  reflection  of  the 
bladder  in  front,  probably  a  little  lower  behind,  and  the  severed  edge 
of  the  peritoneum  stripped  down  with  the  handle  of  the  scalpel  for  the 
purpose  of  making  peritoneal  flaps.  The  next  step  is  a  most  important 
one :  it  is  the  ligation  of  the  uterine  arteries.  This  is  done  in  the  broad 
ligaments,  outside  of,  but  close  to,  the  cervix.  Care  must  be  taken  to 
avoid  the  ureter  on  the  one  hand  and  the  cervical  tissue  on  the  other. 
The  ligature  may  either  be  placed  within  the  folds  of  the  severed  liga- 
ments, or,  which  is  preferable,  made  to  encircle  the  double  fold  of  the 
ligament  and  artery  in  one  sweep ;  action  here  will  depend  upon  the 
size  of  the  pedicle  and  the  consequent  separation  of  these  folds.  The 
constant  traction  which  is  made  upon  the  pedicle  by  the  assistant  who 
is  holding  the  tumor  serves  to  draw  out  and  elongate  the  cervix  after 
the  peritoneal  covering  has  been  incised,  and  thereby  to  permit  deeper 
incision  into  the  neck,  which  is  next  amputated  with  the  knife  by  a 
wedge-shaped  incision.  The  stump  is  now  grasped  with  a  small  vol- 
sella  forceps,  and  further  trimmed  and  reduced,  if  necessary,  so  that 
the  entire  supravaginal  portion  is  removed  before  it  is  dropped  back 
into  the  pelvis.  The  cervix  being  now  released,  it  immediately  recedes, 
and  by  the  retractive  and  elastic  properties  of  the  vagina  is  drawn 
deeply  into  the  pelvis,  where  it  is  buried  out  of  sight  by  the  peritoneal 
flaps  covering  it.  These  flaps  have  been  rendered  so  taut  by  the  liga- 
tures which  have  been  placed  that  usually  as  the  cervix  recedes  into 
the  pelvis  they  close  over  it  like  elastic  bands.  The  cervix  is  now  in 
its  natural  position  and  without  a  ligature  or  suture  in  its  tissues.  The 
operation  is  finished  by  infolding  the  edges  of  the  peritoneal  flaps, 
which  may  be  secured  by  Lembert  sutures  if  necessary.  I  have  not 
found  this  necessary  if  the  ligatures  which  secured  the  uterine  arteries 
had  also  grasped  the  severed  folds  of  the  broad  ligaments,  for  this  so 
tightens  them  that  the  sides  are  brought  forcibly  together  when  the 
cervix  is  drawn  under.  The  bladder  and  surrounding  tissues  aid  also 
in  closing  the  pelvic  cavity.  Nothing  whatever  is  done  to  the  cervical 
canal.  The  portion  of  the  broad  ligament  embraced  in  the  first  ligature 
is  the  same  structure  that  forms  the  ordinary  ovarian  pedicle,  minus 
the  Fallopian  tube.  The  other  ligatures  close  the  opened  broad  liga- 
ment, as  a  rule.  If  any  other  vessels  are  found  spurting,  they  are  of 
course  ligated.  I  have  not  found  it  necessary  to  employ  the  temporary 
elastic  ligature.  The  steps  of  the  operation  vary  somewhat  to  suit  the 
complications  which  may  be  present  in  the  individual  case,  but  the  gen- 
eral direction  and  conclusion  are  practically  the  same  in  all  cases." 

Extra-pcritoncal  Treatment  of  the  Stump. — This  method  should  be 
selected  only  when  great  haste  is  demanded  because  of  the  patient's 


746  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

condition.  The  same  steps  are  followed  as  in  the  intra-peritoneal  treat- 
ment of  the  stump  to  the  point  of  amputatin<j  through  the  supravaginal 
portion  of  the  cervix.  After  the  broad  ligaments  have  been  ligated  and 
cut  from. their  attachment  to  the  body  of  the  uterus  on  either  side,  and 
the  uterus  and  tumor  delivered  through  the  abdominal  incision,  a  liga- 
ture or  Koeberle's  clamp  is  applied  about  the  cervix  immediately  above 
the  vesical  fold  of  peritoneum.  Transfixion-needles  are  placed  at  right 
angles  just  above  the  ligature,  and  the  amputation  is  made  about  three- 
fourths  of  an  inch  above  the  needles.  The  parietal  peritoneum  is 
stitched  to  the  stump,  and  the  abdominal  incision  closed  tightly  about 
it.  The  pins  rest  upon  the  abdominal  wall,  pressure  being  avoided  by 
rolls  of  sterilized  gauze.  The  stump  is  covered  with  boric  acid  or 
iodoform  powder,  and  the  wound  dressed  with  a  sterilized  absorbent 
dressing.  If  the  clamp  is  used,  it  should  be  tightened  each  day  as 
occasion  demands. 

Total  Abdominal  Hysterectomy. — The  vagina  is  prepared  as  for  a 
vaginal  hysterectomy.  If  a  rapid  operation  is  demanded  because  of 
the  condition  of  the  patient,  time  will  be  gained  by  first  proceeding,  as 
in  vaginal  hysterectomy,  by  making  an  incision  around  the  cervix  at  its 
junction  with  the  vaginal  mucous  membrane,  and  ligating  the  broad 
ligaments  as  high  as  possible.  The  patient  is  then  placed  in  the  Tren- 
delenburg position,  the  abdomen  opened  in  the  usual  manner,  the  tumor 
delivered,  and  the  broad  ligaments  ligated  and  incised.  Thus  the  ute- 
rus, including  the  cervix,  can  be  removed  entire,  and  the  vaginal  open- 
ing closed  by  buried  catgut  sutures.  The  usual  method  is  to  open  the 
cul-de-sac  from  above  by  making  a  free  incision  about  the  cervix  at  the 
internal  os  and  stripping  down  the  peritoneal  covering  with  a  blunt  in- 
strument till  the  cervix  is  freed  from  its  attachments. 

Drainage  is  rarely  indicated,  and  when  it  is  it  should  be  made 
through  the  vagina  by  pieces  of  gauze.  The  vagina  is  packed  with 
iodoform  gauze  previous  to  the  operation.  To  avoid  injury  to  the 
bladder,  it  is  well  to  partly  fill  it  with  a  mild  sterilized  solution.  The 
opening  from  the  vagina  is  either  closed  with  catgut  or  the  vagina  is 
packed  from  above  with  iodoform  gauze. 

XI.   UTERINE   POLYPI. 

Polypi  of  the  cervix  are  either  granular  or  fibroid,  the  latter  being 
less  common.  They  are  usually  single,  but  may  be  multiple  ;  rarely 
do  they  attain  any  considerable  size.  The  pedicle  is  constricted  and 
long,  oftentimes  permitting  the  protrusion  of  the  polypi  through  the 
external  os.  A  catarrhal  glandular  endocervicitis  is  an  almost  universal 
accompaniment,  and  the  secretion  is  at  times  offensive  in  odor  and  pro- 
fuse.    Spontaneous  enucleation  is  not  infrequent. 

Polypi  of  the  Uterus. — No  sharp  line  of  distinction  can  be  drawn 
between  submucous  fibroids  and  fibroid  polypi,  the  submucous  fibroid 
often  being  transformed  into  a  fibroid  polypus  by  the  contracting  uterus 
forcing  the  tumor  into  its  lumen — an  attempt  at  spontaneous  enucle- 
ation. The  pedicle  may  be  long  enough  to  permit  the  tumor  to  pro- 
trude into  the  vagina. 

Suppurative  endometritis  is    a  frequent  complication,  and    chronic 


niSEASES  AND   INJURIES   OF  FEMALE    GENERATIVE    ORGANS.     747 

metritis  invariably  exists.  Thus  the  uterus  is  generally  enlarged  and 
its  cavity  deepened. 

Symptoms. — These  do  not  vary  from  those  of  chronic  endometritis  and 
metritis,  save  possibly  in  the  severity  and  frequency  of  uterine  hemorrhage 
and  the  profuse  leukorrheal  discharge.  Uterine  contractions  (cramps), 
profuse  leukorrhea,  increased  menstruation,  weight  and  bearing-down 
sensation  in  the  pelvis,  and  backache  go  to  make  up  the  clinical  picture. 
The  hemorrhage  may  be  continuous  and  oozing,  or  profuse  and  alarming. 

Treatment. — A  polypus  of  the  cervix  when  the  pedicle  is  slender  is 
best  removed  by  torsion,  followed  by  the  usual  treatment  for  endo- 
cervicitis.  Where  the  base  is  broad  it  may  be  necessary  to  excise  the 
growth  and  close  the  resulting  v.'ound  with  sutures. 

Polypi  of  the  uterus  are  also  removed  by  torsion,  followed  by  cu- 
rettage and  packing  of  the  uterus  with  gauze,  as  advised  for  the  treat- 
ment of  endometritis.  Where  the  growth  is  large  it  may  be  neces- 
sary to  remove  it  piecemeal  until  the  pedicle  can  be  reached  and 
excised. 

XII.    MALIGNANT   DISEASES    OF    THE   FEMALE  GENITAL    ORGANS. 

Under  malignant  diseases  will  be  classed  sarcoma,  epithelioma,  and 
carcinoma,  which  may  be  primary  or  secondary  degeneration  of  benign 
growths,  notably  fibroids. 

Bxtemal  Genitals. — Malignant  diseases  of  the  external  genitals 
are  of  rare  occurrence.     By  far  the  most  frequent  is 

Epithelioma,  which  develops  as  a  small  whitish  or  grayish  nodule 
with  uneven  surface,  painless  and  hard,  located  usually  upon  the  inner 
surface  of  the  labia  majora.  The  progress  of  the  disease  is  slow,  and 
may  not  attract  attention  until  the  growth  becomes  stimulated  by  ex- 
ternal irritation  or  by  some  unknown  cause.  The  blood-supply  to  the 
growth  is  then  increased ;  the  tumor  rapidly  infiltrates  neighboring 
structures,  and  there  is  formed  an  ulcer  which  spreads  slowly 
but  surely,  with  an  adv^ancing  margin  which  is  hard,  raised,  and  of  a 
bluish  color.  The  induration  advances  rapidly,  a  disagreeable  fetid 
odor  arises  from  an  ichorous  purulent  secretion,  and  the  ulcer  steadily 
advances  more  and  more  rapidly  along  the  mucous  surface  of  the 
labium.  Through  the  irritating  influence  of  the  secretions  papillary 
excrescences  often  spring  from  the  margin  and  bed  of  the  ulcer,  and  at 
times  assume  enormous  proportions.  The  tendency  of  the  ulcer  and 
indurated  margin  is  to  extend  inward,  involving  the  labia  minora  and 
clitoris,  then  the  vaginal  wall ;  rarely  does  it  spread  over  the  skin- 
surface.  Externally,  late  in  the  process,  the  destruction  may  extend 
to  the  perineum  and  inner  side  of  the  thigh.  The  inguinal  glands 
become  involved  after  ulceration  has  fully  developed ;  they  may  break 
down  into  a  caseous  mass,  or,  becoming  secondarily  infected  with 
pus-organisms,  an  abscess  develops  which  discharges  externally. 
Pruritus  is  of  almost  constant  occurrence,  and  is  thought  by  some 
authorities  to  be  a  cause  and  not  an  effect  of  epithelioma.  When 
ulceration  begins,  pain  is  experienced,  increasing  in  intensity  propor- 
tionate to  the  size  of  the  ulceration.  Cachexia  develops,  but  not  to  so 
marked  a  degree  as  in  carcinoma.     The  patient  gradually  loses  flesh, 


748  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

tlic  secretion  becomes  very  offensive,  hemorrhage  is  infrequent,  and 
death  will  occur  in  about  two  years  after  ulceration  begins,  though  the 
primary  nodule  may  exist  for  years  and  even  escape  notice. 

TrcatDioit  consists  in  immediate  and  free  excision  of  the  growth, 
including  the  neighboring  tissue.  Where  the  ulceration  has  advanced 
beyond  control  the  treatment  resolves  itself  into  palliative  measures  ; 
the  surface  is  kept  clean  by  frequent  washing  with  antiseptic  solu- 
tions and    the  application  of  absorbent    sterilized  dressings. 

Sarconia  of  the  external  genitals  is  exceedingly  rare,  and  is  usually 
located  in  the  labia  majora,  starting  as  a  hard  nodule  beneath  the 
mucous  surface  and  rapidly  spreading  to  the  skin.  Ulceration  soon 
takes  place,  and  an  abundant  secretion  is  discharged  from  a  deep, 
ragged  ulcer.  The  further  progress  is  rapid  and  of  short  duration  ;  all 
the  symptoms  of  epithelioma  are  exaggerated  ;  the  pain  is  severe,  the 
leukorrhea  profuse  and  very  offensive ;  hemorrhage  may  even  threaten 
life  and  emaciation  and  cachexia  are  soon  followed  by  death.  The 
inguinal  lymphatics  are  early  involved,  and  metastatic  growths  develop 
in  distant  parts  of  the  body. 

Trcattncnt. — Early  and  free  excision.  When  seen  late  in  the  devel- 
opment of  the  disease  only  palliative  measures  may  be  of  service. 

Sarcoma  of  the  uterus  may  be  primary  or  secondary ;  when 
secondary  it  is  usually  a  malignant  degeneration  of  fibroids  or  fibro- 
myxomatous  tumors. 

The  most  usual  form  is  that  of  fibro-sarcoma.  This  resembles  in 
gross  structure  and  location  the  various  forms  of  uterine  fibroids — that 
is,  the  submucous,  interstitial,  and  subperitoneal  varieties.  Histologi- 
cally, it  is  either  the  round-  or  spindle-celled  variety,  the  former  being 
the  most  frequent.  Rarely  do  the  sarcoma-cells  infiltrate  the  uterine 
tissue  in  a  diffused  manner.  The  cervix  is  seldom  involved,  as  in  car- 
cinoma. The  submucous  tumors  form  polypoid  excrescences,  are 
usually  of  the  round-cell  variety,  and  to  the  naked  eye  give  the  appear- 
ance of  brain-tissue.  The  surrounding  structures  are  rapidly  invaded, 
and  adhesions  form  which  bind  the  uterus  to  the  abdominal  wall. 

Etiology. — Nulliparae  are  specially  predisposed,  and  the  menopause 
seems  to  be  the  selected  time,  though  sarcomata  have  been  known  to 
occur  prior  to  puberty. 

Myo-fibromata  are  prone  to  degenerate  into  sarcomata. 

Symptoms. — The  first  symptom  to  be  noticed  in  the  majority  of  cases 
is  menorrhagia,  and  later  metrorrhagia.  Pain  when  present  is  due 
either  to  the  contraction  of  the  uterus  in  the  attempt  to  expel  the 
tumor,  and  hence  simulates  labor-pains,  or  is  due  to  the  pressure  of 
the  growth  upon  neighboring  nerves  and  muscles,  causing  pain 
radiating  down  the  thigh  and  painful  contractions  of  the  psoas  and 
iliacus  muscles.  A  watery  discharge,  which  later  assumes  a  disagree- 
able odor,  is  a  frequent  event.  The  body  of  the  uterus  is  increased  in 
size  and  the  cavity  increased  in  depth.  In  the  submucous  variety  the 
cervix  may  be  patulous  to  the  examining  finger,  and  the  tumor  may  be 
palpated  as  a  soft,  projecting  mass.  Sometimes  the  growth  protrudes 
through  the  cervical  canal  into  the  vagina,  and  in  some  instances 
spontaneous  expulsion  has  occurred.  Sloughing  of  the  tumor,  ac- 
companied by  a  disagreeable  odor,  occurs  late  in  the  submucous,  and 


DISEASES  AND   INJURIES   OF  FEMALE    GENERATIVE    ORGANS.     749 

less  frequently  in  the  subserous,  variety.  The  effect  upon  the  general 
health  is  pronounced  and  rapid ;  there  is  a  rapidly-developed  cachexia ; 
loss  of  strength  and  flesh  is  marked  in  a  short  time,  and  death  occurs 
from  septicemia,  peritonitis,  exhaustion,  or  metastasis.  Metastatic 
growths  first  occur  in  the  lymphatics  and  surrounding  pelvic  tissue ; 
later,  in  the  lung  and  liver. 

Diagnosis. — The  diagnosis  can  only  be  made  by  the  aid  of  the 
microscope,  but  the  rapidity  of  the  growth,  the  rapid  and  pronounced 
effect  upon  the  general  health,  the  occurrence  of  the  menopause,  the 
occurrence  of  hemorrhage  after  menstruation  has  long  ceased,  the 
intense  pain  and  foul  watery  discharge,  the  presence  of  a  fibroid  tumor, 
which  after  existing  for  a  long  time  with  no  great  discomfort  suddenly 
begins  to  grow  rapidly  and  to  bleed,  and,  lastly,  the  soft  sensation  upon 
palpating  the  growth,  are  characteristics  which  point  to  sarcoma. 

Fungous  endometritis  may  simulate  sarcoma,  but  this  condition  is 
rarely  found  after  the  menopause.  There  is  no  pain,  no  increase  in 
size  of  the  uterus,  no  watery  foul  discharge,  no  cachexia  and  loss  of 
flesh  ;  the  os  is  not  patulous,  and  no  soft  circumscribed  growth  can  be 
palpated.  The  microscopic  examination  of  the  product  of  curette- 
ment  will  settle  the  diagnosis,  though  repeated  examinations  may  be 
necessary. 

Uterine  fibroids  may  at  times  grow  rapidly,  and  the  question  of 
their  benign  or  malignant  character  may  arise.  In  uterine  fibroids  the 
growth  is  never  so  rapid,  the  effect  upon  the  general  health  is  not  as 
great.  They  seldom  increase  in  size  after  the  menopause.  They  are 
seldom  associated  with  a  watery  discharge,  metastatic  growths  never 
occur,  and  the  tumor  never  returns  after  complete  removal.  The 
microscope  will  relieve  all  doubt. 

Carcinoma  is  differentiated  from  sarcoma  by  the  microscope.  It  is 
possible  to  remove  the  entire  growth  with  more  certainty  in  sarcoma 
than  in  carcinoma,  because  the  lymphatics  are  late  to  be  involved. 
The  tumor  is  early  recognized  as  compared  with  sarcoma. 

Treatment. — Operative. — Total  hysterectomy  when  the  surrounding 
tissue  is  not  involved. 

Palliative. — Where  it  is  impossible  to  remove  the  entire  growth 
palliative  measures  must  be  adopted.  These  consist  in  relieving  pain 
with  opiates,  controlling  hemorrhage  by  curettage,  followed  by  cau- 
terizing with  the  Paquelin  thermo-cautery  or  with  chromic  acid,  zinc 
chlorid,  or  nitric  acid,  and  correcting  the  disagreeable  odor  with  dis- 
infectant and  deodorizing  solutions.  Supporting  treatment  must  be 
given  and  the  bowels  regulated.  Opiates  for  the  relief  of  pain  should 
not  be  withheld. 

Carcinoma  of  the  Cervix. — Etiology. — Carcinoma  of  the  cervix 
occurs  most  frequently  between  the  ages  of  thirty  and  fifty.  Multiparae 
are  more  susceptible  than  primiparae.  Lacerations  of  the  cervix  with 
everted,  eroded  lips  are  fruitful  sources  for  the  development  of  car- 
cinoma of  the  cervix  ;  coition  and  locomotion,  causing  irritation  of  such 
surfaces,  are  exciting  causes. 

Catarrhal  inflammation  is  an  undoubted  predisposing  cause,  particu- 
larly when  associated  with  erosions  and  excoriations.  It  has  long  been 
observed  that  carcinoma  selects  the  site  where  two  kinds  of  epithelial 


750  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

cells  meet,  as  in  the  rectum,  the  lips,  and  external  os  of  the  cervix.  It 
is  found  more  frequently  in  the  white  race  than  in  the  negro,  and  in  the 
lower  more  often  tiian  in  the  upper  classes  of  society.  Heredity  plays 
an  important  part  in  the  causation.  Carcinoma  of  the  cervix  is  found 
as  a  cauliflower  growth  springing  from  the  vaginal  portion  of  the  cer- 
vix and  protruding  into  the  vagina.  Nodular  growths  may  spring 
from  the  cervical  mucous  membrane,  and  finally  ulcerate  and  invade 
the  surrounding  structures.  Superficial  infiltration,  rapidly  followed  by 
extending  ulceration,  progressively  involving  adjacent  tissues,  is  one  of 
the  earliest  of  the  recognized  forms  of  carcinoma  of  the  cervix. 

Symptoms. — Hemorrhage  is  the  most  prominent  symptom,  and,  as 
a  rule,  it  first  directs  the  patient's  attention  to  her  condition.  If  occur- 
ring before  the  menopause,  the  menstrual  flow  is  increased,  and  later 
hemorrhage  occurs  in  the  intervals  between  menstrual  periods.  Hem- 
orrhage occurs  earliest  in  the  superficial  ulcerative  type.  It  may  be  so 
severe  as  to  be  dangerous,  and  anemia  may  develop  to  an  alarming  de- 
gree. When  ulceration  has  developed  the  discharge  acquires  a  sicken- 
ing odor  and  is  of  a  dark  color.  Pain  may  not  be  experienced  until 
the  growth  is  beyond  operative  interference.  It  is  the  result  of  the  in- 
volvement of  the  pelvic  connective  tissue,  and  is  directly  proportionate 
to  the  extent  of  the  infiltration  and  area  of  ulceration.  The  pain  is 
lancinating  or  burning,  and,  infrequently,  colicky.  Where  the  neigh- 
boring organs  become  invaded  numerous  symptoms  arise  which  are 
referable  to  the  region  involved.  Chronic  peritonitis  develops  and  gives 
rise  to  the  drawing,  sharp,  shooting  pains  occasioned  by  the  presence 
of  adhesions.  Vesical  tenesmus  and  dysuria  are  occasioned  by  the  in- 
vasion of  the  bladder.  The  ureters  may  become  occluded,  giving  rise 
to  hydronephrosis.  When  ulceration  ensues  vesico-vaginal  fistula  may 
be  developed.  When  the  rectum  becomes  involved  there  are  rectal 
tenesmus,  bloody,  offensive  stools,  possibly  stricture,  and  late  in  the 
process  recto-v^aginal  fistula  from  ulceration. 

The  effect  upon  the  general  health  is  characteristic :  cachexia,  rapid 
loss  of  flesh  and  strength,  constipation  alternating  with  diarrhea, 
later  constant  diarrhea,  and,  lastly,  uremic  symptoms  from  partial  or 
complete  closure  of  one  or  both  ureters,  give  the  familiar  clinical  pic- 
ture. Death  occurs  from  uremia  and  from  exhaustion  brought  on  by 
the  repeated  hemorrhages,  vomiting,  loss  of  appetite,  diarrhea,  profuse 
and  foul-smelling  discharge,  and  the  severe  pain.  Peritonitis  may  be 
the  cause  of  death. 

Where  a  fibroid  is  gangrenous  and  sloughing  the  fetid  discharge, 
frequent  hemorrhages,  general  emaciation,  and  cachexia,  all  point  to 
the  existence  of  a  carcinoma.  The  os  externum  is  tightly  stretched 
so  as  to  form  a  thin  diaphragm  ;  the  examining  finger  is  introduced 
between  it  and  the  sloughing  mass. 

The  diagnosis  should  always  be  made  by  the  aid  of  the  microscope. 
The  nodular  variety  may  be  distinguished  from  fibroids  by  the  more 
rapid  growth,  softer  consistency,  healthy  surrounding  tissue,  and  on 
cross-section  the  growth  is  soft  like  marrow,  while  the  fibroid  cuts  with 
considerable  resistance.  The  mucous  membrane  is  not  as  adherent  to 
the  fibroid  as  to  the  carcinoma.  The  microscopic  examination  will  be 
conclusive. 


DISEASES  AND   INJURIES   OF  FEMALE    GENERATIVE    ORGANS.     75 1 

Catarrhal  inflammation  may  be  roughly  distinguished  from  the 
superficial  ulcerative  form  by  its  resisting  the  examining  finger,  while 
carcinoma  readily  breaks  down.  The  absence  of  ulceration  speaks 
strongly  against  carcinoma,  and  the  presence  of  numerous  distended 
follicles  with  a  discharge  of  pure  mucus  is  characteristic  of  catarrhal 
inflammation. 

In  the  early  development  the  microscope  alone  will  decide ;  when 
ulceration  has  advanced  to  an  extreme  degree,  no  trouble  will  be  ex- 
perienced in  making  a  diagnosis. 

Where  we  are  forced  to  wait,  the  subsequent  course  of  the  disease 
will  usually  make  the  case  clear.  Where  the  papillomata  present  a 
polypoid  form  they  may  be  confused  with  benign  polypi,  in  which  case 
the  cancerous  nodules  may  be  seen  and  felt,  but  the  diagnosis  must 
rest  with  the  microscope. 

The  extent  to  which  the  tissues  are  invaded  is  a  most  important 
question  to  decide.  Vagino-abdominal  and  rectal  examination,  with 
traction  upon  the  cervix,  will  usually  bring  the  indurated  mass  within 
reach  of  the  examining  finger. 

The  average  duration  of  the  disease  is  difiicult  to  estimate,  because 
the  growth  is  rarely  recognized  till  late  in  its  development.  The  prob- 
able duration  is  one  year  and  a  half  to  two  years.  Only  when  confined 
to  the  cervix  is  there  hope  of  permanent  removal  of  the  growth. 

Treatment. — Palliative  treatment  must  be  resorted  to  when  total 
extirpation  of  the  infected  tissue  cannot  be  accomplished,  and  is  to 
be  directed  to  relieving  distressing  symptoms.  Unfortunately,  the  large 
majority  of  cases  which  are  observed  by  the  surgeon  for  the  first  time 
are  beyond  the  possibility  of  a  radical  operation.  The  onset  is  so  in- 
sidious that  the  broad  ligaments  and  pelvic  connective  tissue  are  usually 
involved  before  the  patient  is  warned  of  her  danger.  Occurring  at  the 
time  when  menstrual  disorders  are  not  unexpected,  no  alarm  arises  at 
the  appearance  of  hemorrhage,  and  not  until  the  discharge  becomes 
profuse  and  offensive  does  the  patient  seek  medical  aid.  In  these  hope- 
less cases  the  treatment  is  to  be  directed  toward  the  control  of  the 
hemorrhage,  altering  the  offensive  discharge,  affording  relief  from  pain, 
and  in  all  possible  ways  rendering  the  patient  more  comfortable. 

The  hemorrhage  is  best  controlled  by  the  use  of  the  curette,  fol- 
lowed by  the  Paquelin  cautery  and  tamponing  the  vagina  with  iodoform 
gauze.  By  this  method,  together  with  hot  vaginal  douches,  life  may  be 
prolonged  and  the  hemorrhage  controlled  for  many  months.  A  number 
of  chemicals  are  used  for  the  same  purpose,  but  with  less  beneficial  effect. 
Of  these  may  be  simply  mentioned  Monsel's  solution,  chlorid  of  zinc, 
nitric  acid,  and  chromic  acid.  Where  the  hemorrhage  threatens  life  it 
may  be  controlled  by  hot  vaginal  douches  and  by  tamponing  the 
vagina  with  iodoform   gauze. 

The  fetid  discharge  is  best  altered  by  douches  of  permanganate  of 
potash  and  hydrogen  peroxid.  The  patient's  strength  should  be  sup- 
ported by  the  use  of  tonics,  the  bowels  should  be  regulated,  and  pain 
must  be  controlled  by  opiates. 

Radical  treatment  rarely  stops  short  of  total  hysterectomy.  When 
seen  very  early  it  may  be  possible  to  eradicate  the  growth  by  ampu- 
tating  the   cervix,  although  it  is  doubtful  if  one  can  ever  be  assured 


752  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

that  the  invasion  has  not  gone  beyond  the  point  of  excision.     Even 
a  partial  amputation  of  the  cervix  is  advised. 

The  operation  is  as  follows  :  The  vagina  is  prepared  as  in  vaginal 
hysterectomy.  By  perineal  and  side  retractors  the  cervix  is  brought 
into  view  and  is  firmly  grasped  by  double  volsellum  forceps.  By 
forcible  traction  upon  the  cervix  the  uterus  is  brought  well  down ;  a 
circular  incision  is  made  completely  around  the  cervix  at  a  point  well 
above  the  carcinomatous  growth  ;  the  cervix  is  amputated  at  this  point 
by  extending  the  incision  into  the  cervical  canal.  The  hemorrhage 
may  be  controlled  by  passing  two  or  more  sutures  before  the  cervix  is 
completely  severed.  The  ends  of  these  sutures  are  left  long,  so  that 
traction  may  be  made  upon  them  after  the  cervix  is  removed ;  the 
vaginal  and  cervical  mucous  membrane  are  next  coapted  by  inter- 
rupted catgut  sutures. 

Schroder's  supravaginal  amputation  should  be  selected  where  vaginal 
hysterectomy  is  not  attempted.  The  technique,  as  described  in  The 
American   Text-Book  of  Gynecology,  is  as  follows  : 

"  The  vagina,  vaginal  portion,  and  external  genitals  are  cleansed  by 
scrubbing  with  a  solution  of  soft  soap  and  washing  in  ether,  alcohol, 
and  bichlorid-of-mercur>'  solution   i  :  2000.     The  instruments  required 
are  to  be  sterilized  by  boiling  them  for  ten  minutes  or  longer  in  soda 
solution,  and  are  then  placed   upon  a  table  at  a  convenient  distance 
from  the  operator  in  the  tray  in  which  they  have  been  boiled.     The 
buttocks,  thighs,  and  mons  veneris  are  guarded  by  a  broad  strip  of 
antiseptic  gauze  having  a  slit  corresponding  to  the  vulvar  orifice.     The 
cervix  is  exposed  by  a  perineal  retractor  and  the  labia  held  apart  by 
assistants.     The  cervix  is  then  seized  in  the  grasp  of  a  double  tenaculum 
or  volsellum  forceps  and  traction  applied,  the  womb  being  drawn  down 
as  far  as  the  elasticity  of  the  uterine  ligaments  will  permit.     A  circular 
incision  is  made  from  one-half  to  one  centimeter  beyond  the  margin  of 
the  diseased  vaginal  mucous   membrane.     There  may  be  considerable 
hemorrhage  from  the  divided  vaginal  arteries  which  will  require  the 
application  of  hemostats  and  ligatures.     After  the  hemorrhage  has  been 
controlled  it  is  easy  with  the  finger  to  separate  the  cervix  from  the 
tissues  front  and  back,  traction  being  made  upon  the  cervix  all  the 
while.     The  connective  tissue  here  contains  no    large  vessels  and  is 
easily  separated.     The    cervix   is   then  drawn    strongly  to    one    side, 
rendering  tense  the  parametric  connective  tissue  on  the  opposite  side, 
which  contains   the    uterine  vessels.     This   tense   tissue,  being  easily 
recognized  by  the  touch,  is  surrounded  by  a  ligature,  as  in  the  ope- 
ration  for  total   extirpation.     The  maneuver  is  best  carried  out  by  a 
half-blunt  staphylorrhaphy  or  aneur>^sm  needle.    After  tightly  tying  the 
ligature  the  included  tissue  is  divided  with  scissors  between  the  ligature 
and  the  cervix.     This  ligation  should  include  the  uterine  artery.     A 
ligature  is  similarly  placed  on  the  opposite  side,  and  the  tissues  divided 
between  it    and  the  cervix.     Frequently  the    tightly-stretched    sacro- 
uterine ligaments  interfere  with  the  drawing  down  of  the  uterus.    They 
may  be  included  in  a  ligature  and  severed,  when  the  uterus  will  readily 
descend.     The  ligatures  should  be  applied  as  far  from  the  cervix  later- 
ally as  possible,  so  that  the  division  of  the  tissues  does  not  occur  close 
to  the  cervix.     The  cervix  is  now  transversely  separated  from  the  body 


DISEASES  AND  INJURIES   OF  FEMALE    GENERATIVE    ORGANS.     753 

of  the  uterus  anteriorly  as  far  as  the  cervical  canal,  and  a  stitch  passed 
through  the  vaginal  wall,  the  connective  tissue,  and  the  divided  cervical 
wall  and  brought  out  in  the  cervical  canal.  This,  being  tightly  tied, 
provides  the  means  for  safely  holding  down  the  stump  after  complete 
separation  of  the  cervix.  Should  there  be  any  hemorrhage  at  this 
stage,  it  may  be  controlled  by  several  similar  sutures.  The  posterior 
wall  of  the  cervix  is  now  cut  through,  and  sutures  passed  as  before 
around  its  circumference,  uniting  the  mucous  membrane  of  the  vagina 
to  that  of  the  womb.  As  the  upper  end  of  the  opened  vaginal  tube  is 
much  larger  than  that  of  the  womb,  the  vaginal  mucous  membrane  is 
thrown  into  folds  by  the  sutures.  On  either  side  are  openings  in  which 
the  ligature  strands  lie  ;  these  require  each  a  stitch  to  effect  closure.  If 
the  ligatures  include  the  uterine  vessels  and  are  tightly  tied,  there 
should  be  very  little  bleeding  in  this  operation.  The  lower  segment 
of  the  womb  may  be  removed  by  this  method  if  desired.  Douglas's 
cul-de-sac  is  frequently  opened  ;  the  author  has  opened  it  several  times, 
but  this  misadventure  did  not  increase  the  danger  of  the  operation. 
The  wound  in  Douglas's  pouch  should  be  immediately  closed  by  a  con- 
tinued suture  of  fine  silk  or  catgut.  The  vagina  is  to  be  carefully 
cleansed  with  boiled  water  and  tamponed  with  iodoform  gauze.  The 
tampons  are  removed  and  renewed,  and  the  vagina  douched  at  intervals 
of  twenty-four  hours.  In  from  five  to  eight  days  the  tampons  ma\'  be 
discontinued,  but  the  daily  douches  are  persisted  in.  On  the  tenth  or 
twelfth  day  the  patient  may  leave  her  bed.  The  early  removal  of  the 
stitches  is  a  matter  of  no  importance,  and  the  longer  they  remain  the 
easier  is  their  removal.  Usually  they  are  removed  on  the  eighth  day. 
If  catgut  be  used  throughout,  there  is  no  need  of  paying  any  attention 
to  them  whatever,  as  the  loop  is  absorbed  and  the  knot  then  falls  off" 

Carcinoma  of  the  Body  of  the  Uterus. — Cancer  of  the  body  of 
the  uterus  presents  itself  either  in  the  form  of  a  diffuse  infiltration  or  as 
polypoid  excrescences.  The  origin  in  either  case  is  the  endometrium. 
Necrosis  follows  upon  infiltration,  surrounding  structures  become  in- 
volved, particularly  the  rectum,  bladder,  and  peritoneum,  adhesions 
about  the  uterus  are  formed,  and  metastasis  involves  the  distant  organs 
and  tissues. 

Symptoms. — A  watery,  fetid,  and  blood-tinged  secretion  is  the  cha- 
racteristic symptom,  though  the  blood  and  the  odor  are  not  constant. 

Pain  is  not  a  constant,  but  is  a  characteristic,  symptom.  It  is  refer- 
able to  the  uterine  contractions  in  their  effort  to  expel  the  contents  of 
the  uterus,  and  hence  are  of  a  colicky  nature,  or  to  the  peritoneum, 
where  a  chronic  peritonitis  is  set  up,  giving  rise  to  the  sharp,  lanci- 
nating pains.  The  pains  may  recur  at  certain  intervals  and  at  certain 
hours.  In  this  respect  they  are  characteristic.  Bimanual  palpation 
will  reveal  a  uterus  more  or  less  enlarged,  possibly  adherent,  and  tender 
to  the  touch.  If  the  os  is  patulous  or  dilated,  carcinomatous  nodules 
and  infiltration  may  be  detected  by  the  examining  finger. 

The  general  effect  upon  the  health  is  often  not  pronounced  until 
late  in  the  course  of  the  disease. 

Diagnosis. — When  hemorrhages  recur  frequently  after  the  meno- 
pause, and  the  usual  causes,  such  as  polypi,  are  excluded,  and  when 
the  discharge  becomes  fetid,  it  is  highly  suspicious  of  carcinoma.    Little 

48 


754  SURGICAL   DIAGNOSIS  AXD    TREATMENT. 

doubt  can  remain  if  the  body  of  the  uterus  is  found  enlarged,  adherent, 
and  nodular  growths  are  felt  on  its  surfaces.  The  uterine  sound  will 
aid  in  detecting  the  sloughing,  irregular  surface.  A  positive  diagnosis 
is  made  by  examining  the  product  of  curettement  by  the  microscope. 

TrcatDicnt. — Operative  treatment  can  only  be  undertaken  when  the 
infiltration  has  not  advanced  beyond  the  uterine  tissues.  Nothing  short 
of  a  total  extirpation  will  suffice,  either  by  the  abdominal  or  vaginal 
route.  Statistics  show  that  hysterectomy  done  for  carcinoma  of  the 
uterus  is  successful  as  to  immediate  and  remote  results  in  33  to  50  per 
cent,  of  cases — a  showing  far  superior  to  that  of  carcinoma  in  any  other 
portion  of  the  body.  Hence  the  injunction  is  imj)erative  to  operate  at 
the  earliest  possible  moment  before  surrounding  structures  are  involved, 
and  in  all  cases  to  remove  the  entire  uterus,  tubes,  and  ovaries.  Where 
the  size  of  the  uterus  will  permit  the  vaginal  route  should  be  selected, 
and  only  in  the  rare  cases  where  the  body  of  the  uterus  is  too  large  to 
be  removed  through  the  vagina  should  the  abdominal  route  be  selected. 

TccJiniquc  of  I  \Tigiiial  Hystcrcctoiiiy. — Many  American  gynecologists 
prefer  to  secure  the  broad  ligament  by  clamps  because  of  the  ease  and 
rapidity  with  which  it  is  done.  The  use  of  clamps  is  open  to  a  number 
of  serious  objections:  i.  The  danger  of  clamping  a  ureter;  2.  Serious 
hemorrhage  from  slipping  of  the  clamps ;  3.  Pressure  of  the  forceps 
upon  the  bladder  and  rectum ;  4.  Interference  with  the  operative  pro- 
cedures by  crowding  the  space;  5.  Preventing  the  closure  of  the  peri- 
toneal cavity,  and  thus  permitting  adhesions  of  the  gut  to  the  raw  sur- 
face and  free  access  of  infection  to  the  peritoneal  cavity. 

The  preparatory  treatment  consists  in  evacuating  the  bowels  and 
sterilizing  the  field  of  operation  in  the  usual  manner. 

Where  the  cervix  is  completely  degenerated,  so  that  traction  cannot 
be  made  with  forceps,  the  mass  is  curetted  or  dissected  away  with  scis- 
sors, the  vaginal  mucous  membrane  grasped  with  volsellum  forceps 
immediately  in  front  of  the  cervix  and  incised  at  a  safe  distance.  The 
bladder  is  then  carefully  dissected  up  till  a  sufficient  portion  of  the  cer- 
vix is  exposed  to  afford  a  firm  grasp  with  the  forceps.  The  cul-de-sac 
of  Douglas  is  then  incised  and  the  peritoneal  fold  stitched  to  the  vagi- 
nal mucous  membrane.  W^ith  the  index  finger  as  a  guide,  a  ligature 
on  a  staff  is  passed  through  the  base  of  the  broad  ligament  on  either 
side,  the  Hgature  including  the  uterine  artery  (Fig.  315).  The  Hgated 
portion  of  the  broad  ligament  is  severed  and  the  uterus  drawn  farther 
into  the  vagina.  The  bladder  is  readily  stripped  from  the  uterus,  and 
the  anterior  cut  margin  of  the  vagina  is  stitched  to  the  vesico-uterine 
fold  of  the  peritoneum  by  a  continuous  catgut  suture.  The  broad  liga- 
ment is  then  ligated  in  section,  step  by  step,  on  either  side  until  the 
uterus  is  free  (Fig.  316).  The  tubes  and  ov^aries  are  to  be  removed 
together  with  the  uterus.  Each  ligature  is  passed  through  the  anterior 
vaginal  mucous  membrane  for  the  purpose  of  preventing  slipping  of  the 
ligatures  and  to  bring  the  stumps  of  the  broad  ligament  outside  the 
peritoneal  cavdty.  Finally  a  ligature  is  passed  through  all  the  stumps 
of  the  broad  ligament  and  out  through  the  anterior  vaginal  mucous 
membrane;  next  the  opening  in  the  vagina  is  closed  with  sutures  and 
packed  with  iodoform  gauze.  The  above  technique  is  essentially  that 
advised  by  Herman  J.  Boldt. 


DISEASES  AND   INJURIES   OF  FEMALE    GENERATIVE    ORGANS.     755 

In  place  of  ligatures,  clamps  may  be  used  in  dealing  with  the  broad 
ligaments.     The  steps  of  the  operation  are  the  same,  except  the  base 


Fig.  315. — Vaginal  hysterectomy:  opening  the  posterior  cul-de-sac,  and  suturing  the  perito- 
neum and  the  mucous  membrane  together  to  control  bleeding  (Martin). 

of  the  broad  ligament  is  clamped  on  either  side  and  the  ligament  cut 
inside  the  clamp.     The  uterus  is  then  drawn  down  and  a  second  clamp 


Fig.  316. — \'aginal  hysterectomy  with  the  ligature:  A,  first  step;  B,  second  step  (Baldy). 

placed  higher  up,  and  a  third  which  includes  the  remaining  portion  of 
the  ligament.     The  uterus  is  removed,  the  handles  of  the  clamps  are 


756 


SURGICAL   DIAGNOSIS  AND    TREATMENT. 


sccurcl)'  tied  with  silk  to  prevent  slippin<^,  and  the  vagina  is  packed 
with  iodoform  gauze.  In  twenty-four  to  forty-eight  hours  the  clamps 
are  removed  and  the  openings  again  loosely  packed.  This  method  is 
not  only  reliable,  but  rapid,  and  where  there  is  much  pelvic  induration, 
involving  the  broad  ligaments,  it  may  be  impossible  to  ligate.  Conva- 
lescence, however,  is  more  protracted. 


Fig.  317. — Hysterectomy  for  cancer  of  the  uterus  (Clark). 


Abdominal  Hysterectomy  luith  Removal  of  a  Considerable  Portion  of 
the  Broad  Ligament. — Dr.  J.  G.  Clark  of  Baltimore  suggests  a  method 
of  extirpating  the  uterus  and  a  great  part  of  the  broad  ligament  without 
injury  to  the  ureters.  Under  cocain  anesthesia  he  first  passes  bougies 
into  the  ureters,  causing  them  to  bulge  out  like  thick  cords,  as  seen  in 
Fig.  317.  The  patient  is  then  anesthetized  and  a  free  abdominal  incision 
made.  Next  the  upper  portions  of  the  broad  ligaments,  with  the 
ovarian  ligaments,  are  ligated.  The  bladder  is  separated,  the  uterine 
arteries  exposed  and  dissected  out  an  inch  beyond  the  vaginal  branches. 


DISEASES  AND  INJURIES   OF  FEMALE    GENERATIVE    ORGANS.     757 

and  here  they  are  tied.     The  next  step  is  to  dissect  the  ureters  free,  and 
to  tie  the  remainder  of  the  broad  ligament  at  a  point  close  to  the  iliac 


Fig.  318. — Hysterectomy  for  cancer  of  the  uterus  (Clark). 

vessels ;    it   is  then  divided   at   its  pelvic  attachment  well   below  the 
cancerous  area.     The  vagina  is  perforated  with  scissors,  tied  in  seg- 


FlG.  319. — The  uterus  after  vaginal  hysterectomy  (Clark). 

ments,  and  divided.     A  strip  of  gauze  is  passed  down  into  the  vagina, 
and  the  peritoneal  flaps  are  sutured  over  the  raw  surface     The  pelvic 


758 


SURGICAL    DIAGNOSIS  AND    TREATMENT. 


"^-^Hiis^^ 


Fig.  320. — Uterus,  broad  ligaments,  and  part  of  vagina  removed  en  masse  (Clark). 


cavity  is  irrigated  and  the  abdominal  cavity  clo.sed  without  drainage. 
Fig.  318  shows  the  peritoneum  dissected  off,  affording  a  lateral  view 


Fig.  321. — Hysterectomy  for  cancer  of  the  uterus  (Clark). 

of  the  uterus  and  bladder,  with  their  relations  to  the  uterine  artery  and 
ureter,  and  the  latter  vessels  to  each  other.  In  Fig.  319  is  shown  the 
condition  of  the  uterus  after  vaginal  hysterectomy.    No  part  of  the  broad 


DISEASES  AND   EVJCKIES   OF  FEMALE    GENERATIVE    ORGANS.     759 

ligaments  or  vagina  is  excised  with  the  uterus.  The  advantages  of  Clark's 
method  are  shown  in  Fig.  320,  which  represents  the  uterine  artery  dis- 
sected out  before  the  broad  ligaments  were  freed  from  their  pelvic 
attachments.  Observe  that  the  greater  part  of  the  broad  ligament  and 
a  considerable  cuff  of  the  vagina  have  been  excised  with  the  uterus  en 
masse.  Fig.  321  represents  the  operation  as  completed.  The  space  left 
by  the  removal  of  the  uterus  is  filled  with  gauze  from  above,  after 
which  the  vesical  and  rectal  peritoneum  are  closed  with  a  continuous 
suture.' 


XIII.   NEW  GROWTHS  OF  THE   TUBES,  OVARIES,   AND   BROAD 

LIGAMENTS. 

New  growths  of  the  tubes  are  of  very  infrequent  occurrence, 
and  rarely  attain  any  considerable  size.  As  with  all  new  growths, 
these  neoplasms  are  classed  as  benign  and  malignant. 

Benign  tumors  are,  in  order  of  their  frequency,  adenomata,  fibro- 
myomata,  cysts,  and  lipomata. 

Adenomata  spring  from  the  glandular  structures  of  the  tube,  and 
form  a  papillomatous  mass  which  occludes  the  lumen  of  the  tubes. 
Histologically,  they  are  composed  of  true  gland-structures. 

Fibro-myoinata  are  usually  subserous  and  sessile  or  pedunculated. 
They  never  attain  any  considerable  size.  They  are  identical  with  the 
fibromata  of  the  uterus,  though  with  a  predominance  of  muscle-fibers. 

Cysts. — These  are  either  subserous  or  interstitial,  never  grow  beyond 
the  size  of  a  hen's  ^g,%,  and  are  usually  much  smaller. 

Lipomata  are  subserous  and  have  been  found  in  rare  instances. 

Malignant  Growths. —  Carcbiomata. — Cancer  of  the  tube  may  be 
primary  or  secondary,  either  from  metastasis  or  direct  extension  from 
the  endometrium ;  less  frequently,  indeed  almost  never,  from  the 
ovary. 

Medullary  carcinomata  have  been  described,  but  the  usual  form  is 
epithelioma,  similar  to  that  of  the  endometrium. 

Sarcomata. — The  sarcomata  may  be  primary,  but  in  almost  every 
instance  are  secondary,  and  rarely  composed  of  sarcomatous  cells 
alone,  the  usual  form  being  a  fibro-sarcoma  and  myxo-sarcoma. 

The  symptoms  do  not  suffice  to  make  a  diagnosis,  and  nothing  but  an 
exploratory  incision  will  reveal  the  condition. 

Benign  growths  are  harmless,  with  the  exception  of  adenomata. 
The  malignant  growths  are  almost  invariably  fatal,  because,  as  a  rule, 
they  denote  the  extension  of  the  growth  from  the  uterus  to  the  sur- 
rounding structures. 

Treatment. — There  is  no  indication  for  the  removal  of  benign  growths. 
Malignant  growths,  together  with  the  uterus,  should  be  extirpated,  pro- 
vided the  infiltration  is  limited. 

New  Growths  of  the  Ovaries. — Benign. — Fibromata  are  of  in- 
frequent occurrence,  and  still  more  rarely  exist  without  more  or  less 
muscle-fibers.  In  gross  and  minute  appearances  they  are  identical  with 
the  subserous  fibromata  of  the  uterus,  and  may  attain  enormous  pro- 
portions.    They  are    sharply  circumscribed,    smooth,    and    lobulated. 

1  Johns  Hopkins  Hospital  Bulletin,  cited  in  Annual  of  the  Medical  Sciences,  1S96. 


760  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

The  secondary  degenerations  are  myxomatous,  calcareous,  fatty,  and 
cystic.  At  any  stage  of  their  development  sarcomatous  tissue  may 
appear.  The  tumor  may  suppurate  or  become  gangrenous,  and  hemor- 
rhages may  occur  in  the  substance  of  the  growth.  Fibro-cystic  tumors 
develop  from  the  distention  of  the  lymph-channels  by  a  clear  lymph 
fluid,  which  may  be  tinged  with  blood  or  become  purulent  from 
secondary  infection  with  pyogenic  organisms. 

Malignant  tumors  of  the  ovary  are,  in  point  of  frequency — 

{ti)  Sarcomata,  which  are  relatively  frequent  in  childhood,  and  are 
of  the  spindle-cell  variety,  though  the  small  round-cell  sarcoma  is  occa- 
sionally seen.  Rarely  is  the  growth  composed  of  sarcomatous  cells 
alone,  the  usual  combination  being  fibro-sarcoma.  The  medullar)^ 
sarcoma  may  be  confused  with  carcinoma  and  require  a  microscopic 
examination.  The  degenerative  changes  are  fatty,  hemorrhagic,  cystic, 
and  calcareous.  The  growth  may  attain  the  size  of  a  fully-developed 
fetal  head,  and  is  peculiar  in  frequently  appearing  simultaneously  in 
both  ovaries.  This  fact,  together  with  the  age,  which  is  usually  early 
womanhood,  the  effect  upon  the  general  system,  and  the  rapidity  of 
the  growth,  will  suffice  to  make  the  diagnosis  highly  probable. 

{h)  Carcinoniata  may  be  primary  or  secondary,  either  by  direct  ex- 
tension from  the  uterus  and  tubes  or  as  a  metastatic  growth  from  the 
breast  or  elsewhere.  Cystic  tumors  of  the  ovary  are  prone  to  become 
cancerous.  They  appear  in  both  ovaries  less  frequently  than  do  sar- 
comata. The  usual  form  is  the  medullary,  which  must  be  differentiated 
from  sarcomata  by  the  microscope.  As  a  rule,  they  appear  later  in  life 
than  sarcomata.  The  usual  forms  of  degeneration  are  fatty,  cystic, 
myxomatous,  and  colloid.  Extension  to  neighboring  structures  occurs 
early,  and  metastasis  rapidly  takes  place ;  conversely,  cancer  of  the 
breast  may  result  in  metastatic  deposits  in  the  ovary ;  less  frequently 
the  disease  comes  from  other  portions  of  the  body. 

Ovarian  Cysts. — Cysts  of  the  ovary  are  usually  classed  as  unilocu- 
lar, multilocular,  and  dermoid  (Fig.  322).  The  unilocular  cysts  are  in 
reality  simple  retention-cysts  formed  by  the  distention  of  the  Graafian 
follicle  with  a  clear  serous  fluid.  Rarely  do  they  exceed  in  size  a  wal- 
nut, rarely  do  they  assume  a  size  sufficient  to  indicate  surgical  inter- 
ference, and  the  rupture  of  their  contents  into  the  peritoneal  cavity  is 
harmless. 

Multilocular  cysts  are  varied  in  their  composition,  and  possibly  in 
their  origin,  though  their  exact  mode  of  formation  is  still  under  debate. 
Probably  the  simpler  varieties  arise  as  the  result  of  an  oophoritis  ;  the 
follicles,  becoming  more  and  more  distended  with  fluid,  and  the  walls, 
becoming  thinned  from  pressure-atrophy,  finally  give  way,  and  two  or 
more  follicles  are  combined  to  form  a  large  one.  In  this  manner  the 
ovary  assumes  the  size  of  an  orange,  rarely  as  large  as  an  adult  head, 
and  is  composed  of  numerous  spaces  distended  with  fluid.  The  more 
complex  cysts  probably  arise  in  the  same  manner,  differing  only  in  the 
additional  involvement  of  the  connective-tissue  framework  and  gland- 
tissue.  The  gland-tissue  proliferates  as  does  the  interstitial  tissue ;  in 
this  manner  papillary  and  adenomatous  excrescences  project  into  the 
cyst-cavities,  forming  great  cauliflower  growths.  Many  authors  em- 
phasize the  importance  of  a  microscopic  examination  of  the  cyst-con- 


DISEASES  AND   INJURIES   OF  FEMALE    GENERATIVE    ORGANS.     76 1 

tents — the  elements  being  a  few  blood-  and  pus-cells,  cholesterin  plates, 
degenerate  epithelium,  and  the  "  ovarian  granular  cells  "  of  Drysdale, 
which  are  not  pathognomonic  of  ovarian  cysts,  but  in  reality  are  epi- 
thelium which  has  undergone  partial  fatty  degeneration. 

Papillomatous  cysts  rarely  attain  any  considerable  size.  Without 
entering  into  a  discussion  of  their  origin  and  pathology,  suffice  it  to  say 
they  present  the  same  external  appearance  as  the  former  cysts,  unless 
the  cyst-wall  has  been  penetrated  by  the  papillomatous  growths. 
Within  the  cyst-wall  are  numerous  dendritic  growths  varying  in  size 


Fig.  322. — Multilocular  cvst  (from  a  photograph  in  the  collection  of  Dr.  Andrews,  Mankato, 

Minn.). 

up  to  that  of  an  orange  ;  the  fluid  within  the  cysts  is  clear  and  watery, 
varying  but  little  from  that  of  the  simple  ovarian  cysts.  These  growths 
are  prone  to  cancerous  degeneration — a  clinical  fact  so  often  observ^ed 
as  to  suggest  the  probability  of  all  being  malignant :  this  is  not  borne 
out  by  pathological  investigation. 

Tubo-ovarian  cysts  probably  arise  from  the  catarrhal  salpingitis  result- 
ing in  adhesions  of  the  fimbriated  extremity  of  the  tube  to  the  ovary ; 
the  tube  fills  with  fluid ;  the  wall  between  a  distended  Graafian 
follicle  and  the  lumen  of  the  tube  gives  way,  and  the  two  are  simul- 


762  Si'KGICAL   D/AGA'OSIS  AXD    TREATMENT. 

taneously  distended.  The  cyst  is  characteristic  in  shape ;  the  tube 
broadens  toward  the  fimbriated  extremity  and  ends  in  a  bulbous  sac. 
It  is  rarely  large,  yet  has  been  known  to  contain  as  much  as  a  quart 
of  fluid.     It  is  usually  bilateral. 

Dermoid  Cysts. — According  to  Johnstone,  dermoid  cysts  arise  from 
the  Graafian  follicle  through  the  faulty  development  of  the  ovum.  They 
occur  at  all  ages  from  infancy  to  adolescence ;  many  attain  the  size  of 
an  adult  head.  They  are  usually  unilateral ;  their  development  is  slow, 
and  oftentimes  they  cease  to  grow  for  a  long  period  of  time. 

Ovarian  cysts  in  the  infant  are  almost  invariably  dermoid.  In  three- 
fourths  of  the  cases  they  are  unilateral.  Adhesions  bind  them  to  ad- 
jacent structures  and  degenerative  changes  are  of  frequent  occurrence. 
The  external  wall  of  the  cyst  is  of  darker  color  than  the  simple  ovarian 
cysts,  and  yellowish  patches  of  fat  are  seen  here  and  there  through  the 
cyst-wall.  The  contents  consist  of  hair,  teeth,  bones,  cartilage,  nerve, 
muscle,  and  nails ;  even  well-formed  organs,  such  as  the  mammae,  are 
occasionally  found.  The  contents  of  the  cysts  vary  from  an  oily  liquid 
to  a  thick  caseous  substance ;  they  are  always  unilocular. 

Svniptoms  of  Ovarian  Tujuors. — Ovarian  tumors  may  attain  a 
considerable  size  before  the  attention  of  the  patient  is  attracted  to  their 
growth. 

Pain  in  the  region  of  the  ovary  occurs  in  a  limited  number  of  cases, 
and  is  in  no  way  directly  proportionate  to  the  size  of  the  growth,  being 
more  the  result  of  the  accompanying  peritonitis.  Associated  with 
ovarian  tumors  there  is  usually  endometritis ;  hence  menorrhagia  is  an 
almost  constant  symptom.  Amenorrhea  is  not  frequent,  and  points  to 
the  existence  of  a  tumor  in  each  ovary  when  occurring  early  in  the 
development  of  the  condition.  Later  it  follows  as  the  result  of  ex- 
haustion and  depletion.  Sterility  is  due  to  the  involvement  of  both 
ovaries  or  to  some  complication,  as  endometritis :  pregnancy  not  in- 
frequently complicates  ovarian  tumors.  Pressure-symptoms  soon 
develop  if  the  growth  remains  in  the  pelvis,  but  if  it  rises  in  the  abdo- 
men the  growth  may  assume  immense  proportions  before  causing 
discomfort.  These  pressure-symptoms  are  constipation,  tenesmus, 
frequent  urination,  dysuria,  pain  in  the  regions  supplied  by  the  sacral 
and  sciatic  nerves,  backache,  heavy  sensation  in  the  pelvis,  edema  of 
the  vulva  and  lower  extremities,  and  hemorrhoids.  When  the  tumor 
has  ascended  into  the  abdominal  cavity  and  developed  to  an  enormous 
size  the  distress  from  pressure  and  weight  is  pitiful. 

Dyspnea  becomes  extreme ;  the  stomach  is  unable  to  retain  food ; 
the  heart's  action  is  embarrassed ;  jaundice  may  supervene  from  pres- 
sure upon  the  bile-ducts  ;  the  skin  becomes  dry ;  emaciation  becomes 
extreme,  and  the  urine  scanty  and  high-colored.  Death  from  ex- 
haustion ends  the  patient's  suffering  unless  some  complication  super- 
venes. 

Diagnosis  of  Ovarian  Tumors. — A  small  cyst  is  frequently  dis- 
covered by  bimanual  examination  when  no  suspicion  of  its  exist- 
ence had  been  entertained.  It  will  be  recognized  as  a  smooth, 
globular,  elastic,  movable  tumor,  lying  to  one  side  or  behind,  very  rarely 
in  front  of,  the  uterus.  If  lying  between  the  layers  of  the  broad  liga- 
ment, the  growth  will  be  more  fixed.     In  all  cases  it  can  be  outlined 


DISEASES  AND   INJURIES   OF  FEMALE    GENERATIVE    ORGANS.     763 

separately  from  the  uterus.  When  the  cyst  has  grown  to  the  size  of  a 
fetal  head  fluctuation  is  elicited,  providing  the  contents  are  fluid.  If 
gelatinous,  the  peculiar  sensation  to  touch  will  be  elicited.  This  fluc- 
tuation may  be  masked  by  thickening  of  the  cyst-wall  from  inflammatory 
adhesions.     Anesthesia  will  facilitate  the  examination  in  such  cases. 

An  exploratory  puncture  with  an  aspirating  needle  may  be  made, 
providing  the  tumor  is  found  in  the  cul-de-sac  or  bulges  into  the  vagina. 
The  cantents  aspirated  may  be  serous,  bloody,  or  purulent,  and,  if 
purulent,  vaginal  incision  and  drainage  may  be  made  at  once.  When 
the  tumor  has  grown  to  the  size  of  an  adult  head,  lying  largely 
within  the  abdominal  cavity,  it  will  be  recognized  on  palpation  by 
its  smooth,  circumscribed,  peculiar  tense,  elastic  sensation.  Fluctuation 
may  not  be  detected,  and  too  much  stress  must  not  be  placed  upon 
this  sign.  The  tumor  is  more  or  less  movable  when  manipulated,  and 
may  also  move  with  the  change  of  the  position  of  the  patient.  The 
percussion-note  over  the  tumor  is  dull  or  flat,  and  this  area  of  dulness 
does  not  change  to  the  most  dependent  portion  of  the  abdominal  cavity 
when  the  patient  lies  on  one  or  the  other  side.  The  position  and  size 
of  the  uterus  should  be  outlined  by  vaginal  examination  ;  the  organ 
will  be  found  to  be  displaced  by  the  tumor — possibly  drawn  upward  by 
the  adhesions,  but  usually  pushed  to  one  side.  The  uterus  will  not  be 
increased  in  size.  When  the  tumor  is  large  inspection  wall  aid  much  in 
the  diagnosis.  The  abdomen  will  not  be  symmetrically  distended, 
being  more  prominent  in  the  region  of  the  tumor.  The  degree  of 
distention  may  be  estimated  by  measuring  the  distance  from  the 
umbilicus  to  either  anterior  superior  spine  of  the  ilium.  If  the  dis- 
tention is  great,  the  superficial  veins  will  be  prominent  on  that  side,  and 
the  linea  albicantia  may  appear  as  in  pregnancy.  Above,  the  limit  of  the 
tumor  may  be  outlined,  but  below,  it  is  lost  in  the  pelvis.  In  extreme 
cases  the  upper  border  may  be  lost  behind  the  arch  of  the  thorax  ;  the 
ribs  bulge  and  the  abdominal  viscera  are  displaced.  In  determining 
the  variety  of  the  cyst — that  is,  w^iether  it  is  unilocular,  multilocular, 
colloid,  or  dermoid — the  following  general  points  may  be  of  serv^ice : 

In  unilocular  cysts  the  surface  is  smooth  ;  even  fluctuation  is  dis- 
cerned at  all  points  with  equal  facility,  and  the  growth  compared  with 
the  multilocular  cysts  is  limited  in  size. 

Multilocular  cysts  attain  enormous  proportions,  are  irregular  in  out- 
line, resistance  is  not  uniform,  fluctuation  may  be  limited  to  a  portion 
of  the  tumor. 

A  dermoid  cyst  may  be  suspected  when  the  tumor  appears  early  in 
life,  when  it  is  of  slow  growth,  accompanied  with  pain  and  exacerbations 
of  peritonitis.  On  palpation  it  imparts  a  doughy  sensation.  Of  course 
when  portions  of  the  cyst,  as  teeth,  bone,  and  hair,  are  discharged 
through  a  fistulous  communication,  the  diagnosis  is  established.  Very 
rarely,  indeed,  are  portions  of  the  tumor  palpated  and  recognized  as 
teeth  and  bone. 

Differential  Diagnosis. —  Tympanites  often  leads  to  a  misappre- 
hension as  to  the  existence  of  a  tumor.  In  tympanitis  the  distention 
is  symmetrical  and  not  constant,  being  aggravated  shortly  after  meals, 
and  is  associated  with  flatulence,  passage  of  gas,  and  rumbling  in  the 
bowel.     The     percussion-note    is    uniformly  tympanitic ;     no    circum- 


764  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

scribed  mass  can  be  palpated,  and  auscultation  will  reveal  gurgling 
sounds  at  all  points. 

PluDitotii  tumors  in  hysterical  subjects  are  often  misleading.  Anes- 
thesia A\-ill  clear  up  the  mj'stery.  Thick,  fat  abdoiiiinal  zoa/Is  are  dis- 
tinguished by  the  great  fat  folds  so  prominent  in  the  sitting  posture ; 
by  the  peculiar  doughy  feel,  so  diflerent  from  the  tense,  elastic  resist- 
ance of  an  ovarian  cyst;  by  the  deep  resonance.  The  "fat-thrill"  of 
Godell  may  simulate  the  cyst-thrill  in  percussion,  but  may  be  muffled 
by  laying  the  hand  of  an  assistant  upon  the  surface  between  the 
examiner's  hands. 

Ascites. — Here  the  history  and  the  presence  of  a  cause  in  the  heart, 
lung,  or  liver  will  facilitate  the  diagnosis  of  ascites.  The  abdomen  is 
distended  symmetrically,  bulging  at  the  sides,  and  more  flattened  in 
front  than  is  the  case  when  a  cyst  is  present.  Fluctuation  is  not  con- 
fined to  the  bulging  area,  which  is  dull  on  percussion  at  the  dependent 
portion,  and  changes  with  the  position  of  the  patient.  This  is  not  true 
of  a  cyst.  Above  the  line  of  dulness  is  tympany.  Vaginal  examina- 
tion is  negative ;  the  uterus  is  not  displaced  and  no  tumor  is  felt.  Cir- 
cumscribed collections  of  fluid  due  to  peritonitis  are  difficult  to  distin- 
guish from  cysts,  but  there  is  usually  a  history  of  peritonitis,  and  the 
tumor  is  more  often  in  the  middle  line  than  to  one  side. 

In  the  presence  of  a  large  accumulation  of  ascitic  fluid  small  cysts 
are  not  often  discovered.  When  suspicion  of  their  presence  exists,  it 
would  be  well  to  tap  the  abdomen  to  draw  off  the  ascitic  fluid,  and  then 
make  a  careful  examination  for  the  cyst.  The  examination  of  the  fluid 
will  aid  in  the  diagnosis.  Ascitic  fluid  coagulates  by  heating ;  it  may 
contain  somQ  blood-cells ;  the  cell-elements  of  cystic  fluid  are  rarely 
present ;  and  the  fluid  lacks  the  viscidity  of  cystic  fluid.  The  specific 
gravity  is  about  10 14,  and  the  color  is  green  and  yellow. 

Pyosalpinx  and  Pelvic  Abscesses. — The  history  will  often  clear  up  the 
diagnosis.  Such  collections  of  pus  are  usually  associated  with  a  history 
of  septic  infection  following  labor  and  abortion  or  a  gonorrheal  infec- 
tion. They  are  generally  accompanied  with  chills,  pain,  fever,  and 
sweating.  Physical  examination  will  elicit  tenderness  and  a  mass  which 
is  fixed  and  does  not  give  the  firm,  elastic  resistance  of  a  cyst.  Rarely 
do  they  attain  any  considerable  size.  If  bulging  into  the  vagina,  the 
exploring  needle  will  settle  the  diagnosis. 

Hydrosalpinx  will  usually  be  readily  distinguished  by  its  elongated, 
tortuous  shape. 

Pelvic  hematocele,  as  a  rule,  is  associated  with  a  history  of  possible 
pregnancy.  It  is  recognized  by  its  peculiar  doughy  feeling,  by  the 
mass  being  fixed  and  not  circumscribed ;  fluctuation  is  indistinct,  and 
the   aspirating  needle  withdraws  blood. 

Ectopic  gestation  must  be  thought  of  Before  the  rupture  there  will 
be  a  growing  tumor  to  one  side  or  behind  the  uterus  ;  it  will  be  boggy 
to  the  touch  and  other  evidences  of  pregnancy  will  be  found.  After 
rupture  there  will  be  a  history  of  sudden  pain,  collapse,  and  the  appear- 
ance of  a  hematocele,  as  described  above. 

Uterine  fibroids  are  usually  distinguished  by  their  greater  degree  of 
resistance. 

Pancreatic  cysts  are  usually  found  in  the  median  line  of  the  epigas- 


DISEASES  AND   INJURIES   OF  FEMALE    GENERATIVE    ORGANS.     765 

trium ;  the  fluid  is  alkaline,  of  low  specific  gravity,  and  contains  fat- 
droplets.  The  epithelial  cells  found  in  ovarian  cysts  are  absent.  The 
stomach  is  displaced  forward. 

Displacement  of  the  kidney  may  be  detected  by  the  shape  of  the 
organ,  by  the  ability  to  replace  it,  and  by  its  consistency. 

Tumors  of  the  kidney  are  usually  found  in  the  young.  They  are 
retroperitoneal,  as  demonstrated  by  inflating  the  colon  over  them.  A 
history  of  hematuria,  pyuria,  and  renal  colic  is  often  given,  and  the 
lessening  in  size  of  the  tumor  simultaneously  with  the  appearance  of 
pus  or  increased  amount  of  water  in  the  urine.  Catheterization  of  the 
pelvis  of  the  kidney  will  be  valuable  in  the  diagnosis  of  pyonephrosis 
and  hydronephrosis. 

Enlarged  spleen  from  malaria,  tumors,  or  leukemia  is  recognized  by 
its  tendency  to  grow  downward  and  inward,  by  its  peculiar  shape,  by 
the  detection  of  the  notch  upon  the  inner  margin,  by  the  examination 
of  the  blood,  and  by  the  history  relating  to  the  case. 

A  distended  bladder  should  not  be  mistaken  for  a  cyst.  Inquire 
into  the  frequency  and  time  of  urination,  the  amount  of  urine  voided ; 
and  the  use  of  the  catheter  will  prevent  possible  errors. 

Impacted  feces  will  be  excluded  by  the  use  of  enemata  and  cathar- 
tics ;  the  tumor  thus  caused  will  be  dull  on  percussion  and  doughy 
on  pressure,  the  indentation  remaining  persistent  after  the  finger  is 
removed. 

Treatment  of  Ovarian  Tumors. — Medical  treatment,  tapping,  electri- 
city, injections  with  iodin  and  astringents,  will  only  be  mentioned  to  con- 
demn them.  It  cannot  be  too  strongly  emphasized  that  the  only  justi- 
fiable treatment  is  surgical  interference.  Tapping  may  be  the  only 
resort  when  the  patient  suffers  from  pressure-symptoms  and  a  surgical 
operation  is  contraindicated. 

Ovariotomy  may  be  said  to  be  indicated  wherever  there  exists  a 
tumor  of  the  ovary.  The  usual  preparations  for  an  abdominal  section 
are  made.  The  Trendelenburg  position  will  be  found  most  advantage- 
ous. The  incision  should  be  in  the  median  line  above  the  pubis,  and 
should  be  long  enough  to  admit  of  ready  manipulation  and  delivery 
of  the  tumor  after  it  has  been  emptied.  The  adhesions  binding  the 
tumor  to  the  parietal  peritoneum  are  broken  up  with  the  fingers  ;  the 
omentum  when  adherent  is  freed  in  a  similar  manner,  or,  if  too 
strongly  attached,  by  amputating  the  adherent  portion.  Great  care 
should  be  exercised  in  separating  adhesions  to  the  intestines ;  the 
adherent  gut  should  be  brought  plainly  to  view,  with  the  sac  well  ex- 
posed. A  trocar  is  plunged  into  the  cyst-cavity  and  the  fluid  allowed 
to  escape.  The  peritoneal  cavity  is  protected  by  sponges.  As  the 
cyst  empties  the  sac  is  grasped  with  the  cyst-forceps  and  traction  made. 
Thus  the  cyst  is  drawn  out  of  the  wound.  The  trocar  is  then  removed 
and  the  opening  in  the  sac  enlarged.  The  contents  are  allowed  to 
escape,  and  the  hand  is  introduced  inside  the  cyst.  Secondary  cysts 
may  be  broken  into  and  discharge  their  contents  into  the  large  cyst- 
cavity.  Traction  upon  the  cyst  is  continued  until  it  is  drawn  outside 
the  abdominal  cavity.  The  pedicle  is  then  ligatcd  and  removed  close 
to  the  uterus. 

The  stump  is  either  cauterized  with  a  Paquelin  cautery  or  with  car- 


766  SURGICAL   DIAGNOSIS  AXD    TREATMENT. 

bolic  acid.  If  the  contents  of  the  cyst  are  not  purulent,  there  is  no  in- 
dication for  irrigation.  If  there  is  suppuration,  irrigation  and  drainage 
should  be  employed.  Where  the  adhesions  are  extensive  and  there  is 
considerable  oozing  a  drainage-tube  should  be  inserted.  Serous  and 
bloody  fluid  should  be  removed  from  the  peritoneal  cavity  by  sterilized 
sponges.     The  wound  is  closed  in  the  usual  manner. 

Occasionally  it  will  be  found  impossible  to  remove  the  cyst  en  masse. 
Such  is  sometimes  the  case  when  the  adhesions  are  too  firm,  the  bleed- 
ing and  shock  too  severe,  or  the  collapse  of  the  patient  renders  a  hasty 
operation  imperative.  In  such  a  case  the  cyst  is  drawn  out  as  far  as 
possible  and  the  extruded  portion  excised.  The  margins  of  the  remain- 
ing portion  of  the  cyst  are  stitched  to  the  abdominal  incision,  and  the 
cavity  drained  by  iodoform  gauze  or  a  glass  drainage-tube. 

XIV.    EXTRA=UTERINE   PREGNANCY. 

Tubal  Pregfnancy. — The  normal  site  of  impregnation  is  in  the 
uterus,  but  sometimes  it  occurs  in  the  tube. 

Etiology. — Little  is  known  concerning  the  cause  of  tubal  pregnancy. 
Most  frequent!}'  it  occurs  after  a  long  period  of  sterility,  though  it  has 
been  known  to  happen  as  early  as  the  age  of  twenty,  and  after  repeated 
normal  pregnancies  or  closely  following  upon  an  abortion,  miscarriage, 
or  labor  at  full  term.  Desquamative  salpingitis  is  thought  by  many  to 
be  the  pathological  condition  most  frequently  responsible. 

As  a  result  of  tubal  pregnancy  the  tube  becomes  thickened,  owing 
to  congestion  and  hypertrophy  of  the  essential  cell-elements.  At  times 
there  is  a  general  or  localized  thinning  of  the  walls  of  the  tube.  The 
ovum  becomes  adherent  to  the  mucous  membrane  by  a  new-formed 
chorionic  membrane ;  later  the  greater  portion  of  the  villi  become 
atrophied  while  the  remaining  villi  form  the  placenta.  When  this 
fetal  body  is  separated  from  its  attachments  hemorrhage  into  the 
chorionic  villi  is  a  universal  result,  and  there  is  developed  from 
the  product  of  conception  what  is  generally  known  as  an  apoplectic 
ovum  or  fleshy  mole.  Early,  it  is  seen  as  a  dark  coagulum  of  blood 
which  in  a  few  days  becomes  of  a  yellow  color,  due  to  a  deposit  of 
fibrin  upon  the  surface.  In  the  center  is  a  cavity  lined  with  a  smooth 
amniotic  membrane  containing  a  clear  amniotic  straw-colored  fluid, 
and  at  times  the  remains  of  an  embryo.  The  presence  of  an  embr>'o 
is  proof  positive  of  the  character  of  the  clot,  and  the  existence  of  cho- 
rionic villi,  as  demonstrated  by  the  microscope,  is  the  next  most  essen- 
tial point  in  diagnosis. 

Rupture  of  the  tube  is  an  almost  inevitable  result,  though  in  rare 
instances  the  fetus  is  destroyed  early  in  its  development  and  remains 
quiescent.  Rupture  of  the  tube  may  be  primary  or  secondary,  and  may 
be  intra-peritoneal  or  extra-peritoneal. 

Primary  rupture  is  the  term  employed  when  the  accident  occurs 
prior  to  the  development  of  the  placenta  at  the  twelfth  week.  When 
rupture  takes  place  into  the  peritoneal  cavity  there  is  grave  danger  of 
fatal  hemorrhage,  the  danger  being  proportionate  to  the  degree  of 
the  development  of  the  ovum.  Peritonitis  is  of  rare  occurrence. 
The    blood    tends    to    collect    in    the    cul-de-sac  of  Douglas    and    to 


DISEASES  AND  INJURIES   OF  FEMALE    GENERATIVE    ORGANS.     '/6y 

become  walled  off  in  the  pelvis  by  the  adherent  omentum  and  intes- 
tines above.  Secondary  hemorrhages  may  follow.  Primary  rup- 
ture of  the  tube  between  the  layers  of  the  broad  ligament,  known  as 
extra-peritoneal  rupture  of  the  tubes,  is  of  less  serious  consequence, 
because  the  extra-ligamentous  pressure  soon  checks  the  hemorrhage. 
The  ovum  may  become  destroyed  and  no  subsequent  injur}-  ensue,  but 
it  may  go  on  to  development  between  the  layers  of  the  broad  ligament, 
and  is  then  called  "  intra-ligamentous  gestation  "  or  "  broad-ligament 
pregnancy." 

Tubal  abortion  is  a  term  applied  to  those  cases  in  which  impreg- 
nation develops  in  the  outer  third  of  the  tube,  and,  the  ostium  abdom- 
inalis  not  being  closed,  the  ovum  is  expelled  through  it  into  the 
abdominal  cavity.  The  danger  of  such  an  event  is  directly  propor- 
tionate to  the  proximity  of  the  ovum  to  the  ampulla  and  to  the  patency 
of  the  ostium  abdominalis,  which  should  close  not  later  than  the  sixth 
or  eighth  week.  After  the  eighth  week  tubal  abortion  does  not  take 
place,  but  the  tube  ruptures  because  of  the  closure  of  the  ostium 
abdominalis. 

Together  with  tubal  abortion  there  is  more  or  less  hemorrhage 
into  the  peritoneal  cavity.  This  may  be  so  abundant  as  to  result  in 
profound  shock  and  death  or  peritonitis  may  dev^elop.  Thus  the  vast 
majority  of  hematoceles  are  occasioned.  Coincident  with  the  develop- 
ment of  the  ovum  in  the  tube  is  the  development  of  a  uterine  decidua, 
which  is  expelled  accompanied  by  hemorrhage.  When  occurring  early 
the  ovum  is  often  not  detected  in  the  blood-clot. 

Tubal  Gestation. — The  placenta  is  formed  almost  exclusively 
from  fetal  tissue,  the  tubal  mucous  membrane  entering  but  little  into 
its  structure  ;  hence  there  is  little  or  no  thickening  of  the  tube,  but,  on 
the  contrary,  the  walls  become  thinned  and  finally  rupture.  The 
decidua  forms  in  the  uterine  cavity  and  around  the  ovum,  and  is  usually 
discharged  during  pregnancy,  with  symptoms  of  miscarriage.  Occa- 
sionally it  is  expelled  in  fragments  and  unnoticed.  The  menstrual 
membrane  of  membranous  dysmenorrhea  must  not  be  mistaken  for 
the  decidual  membrane.  The  decidual  membrane  is  larger,  thickened, 
and  presents  a  shaggy  external  surface,  and  at  its  three  angles  are  the 
openings  corresponding  to  the  Fallopian  tubes 'and  the  internal  os. 
The  internal  surface  is  dotted  with  the  orifices  of  the  uterine  glands. 
When  the  fetus  lies  above  the  placenta  in  the  tube  the  placenta  is  crowded 
down  between  the  layers  of  the  broad  ligament,  and  when  the  fetus  lies 
below  the  attachment  of  the  placenta  the  latter  is  crowded  high 
into  the  abdomen.  These  remarkable  displacements  not  only  result 
in  alteration  of  the  placental  structure  and  function,  but  have  a  jeop- 
ardizing effect  upon  the  life  and  health  of  the  mother  and  fetus. 
The  danger  to  the  mother  is  hemorrhage  from  the  placental  site  into 
the  peritoneal  cavity  or  gestation-sac.  The  fetus  is  usually  ill-formed 
or  under-sized ;  club-foot,  spina  bifida,  hydrocephalus,  and  like  de- 
formities are  frequently  present.  Rarely  does  the  fetus  live,  but  even 
after  its  death  the  placenta  may  continue  to  grow  and  attain  enormous 
proportions.  A  dead  fetus  may  become  viuvnuificd ;  in  other  cases  it 
becomes  partially  converted  into  a  litJwpcdion  by  a  deposit  of  lime  salts 
in  the  superficial  structures.     The  fetal  body  and  placenta  may  become 


768  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

gangrenous  or  suppurate,  and  death  ensue  from  septic  infection  or 
peritonitis. 

Sccividary  rupture  of  the  gestation-sac  may  occur  at  any  time  after 
the  formation  of  the  placenta  at  the  twelfth  week.  If  the  placenta  lies 
above  the  fetus,  crowding  it  into  the  pelvis,  there  is  great  danger  of 
rupture  of  the  placenta  with  fatal  intra-peritoneal  hemorrhage.  When 
the  fetus  lies  above  the  placenta,  the  latter  may  finally  rupture  into  the 
peritoneal  cavity  without  dangerous  hemorrhage,  and  the  fetus  con- 
tinue to  live  and  accommodate  itself  to  its  environments.  Not  always 
does  the  sac  rupture.  Spurious  labor  may  occur  at  the  expected  time, 
the  amniotic  liquor  become  absorbed,  and  the  fetus  mummifies,  only  to 
be  accidentally  discovered  years  afterward. 

J.  Bland  Sutton  says :  "  There  is  not  such  a  thing  as  primary  peri- 
toneal pregnancy.  All  forms  of  cxtra-titcrinc  pregnancy  pass  their 
primary  stages  in  the  Fallopian  tube." 

Tubo -uterine  pregnancy,  or  interstitial  pregnancy,  as  it 
is  sometimes  called,  is  a  term  applied  to  the  condition  in  which 
the  fetus  dev^elops  in  that  portion  of  the  Fallopian  tube  lying  in 
the  uterine  wall.  In  consequence  of  the  structures  of  the  walls  the 
sac  does  not  become  thinned,  but  greatly  hypertrophied,  just  as  does 
the  uterus  ;  hence  rupture  does  not  occur  so  early  as  in  the  other 
forms,  and  the  rupture  may  be  intra-peritoneal  or  intra-uterine.  Tubal 
pregnancy  must  not  be  confused  with  pregnancy  in  a  rudimentary  horn 
of  the  uterus.  In  tubal  pregnancy  the  decidua  is  intra-uterine,  and  in 
pregnancy  of  a  rudimentary  cornu  the  decidua  lies  within  the  cornu. 
A  few  cases  are  on  record  in  which  there  existed  simultaneously  an 
intra-uterine  and  an  extra-uterine  fetus. 

Symptoms  of  Tubal  Pregnancy. — The  usual  signs  of  early  preg- 
nancy are  not  always  present,  but  when  discernible  are  valuable  diag- 
nostic points.  The  breasts  may  not  undergo  the  usual  development, 
and  there  may  be  no  amenorrhea.  In  such  cases  the  diagnosis  must 
depend  upon  a  physical  exploration.  The  woman  herself  may  not  be 
aware  that  she  is  pregnant. 

Rupture  of  the  tube  manifests  itself  by  a  sudden  pain  or  sense  of 
something  having  given  way  in  that  region  ;  then  follow  other  symp- 
toms referable  to  internal  hemorrhage.  If  the  rupture  has  occurred 
through  the  placental  site  into  the  peritoneal  cavit}%  the  loss  of  blood 
may  be  enormous  ;  the  patient  becomes  faint,  pallor  rapidly  develops, 
the  respiration  becomes  sighing,  the  pulse  weak  and  rapid,  the  extremi- 
ties cold,  and  the  temperature  subnormal.  Death  ma}'  follow  in  two  or 
more  hours.  If  the  rupture  occurs  between  the  layers  of  the  broad 
ligament,  the  extra-vascular  soon  equalizes  the  intra-vascular  pressure, 
and  hemorrhage  is  checked  without  serious  effect  upon  the  patient. 
Coincident  with  the  rupture  there  are  frequently  hemorrhage  from  the 
uterus  through  the  vagina  and  the  expulsion  of  the  decidua  oi  masse 
or  in  shreds. 

After  the  third  month  tubal  pregnancy  gives  the  following  signs 
and  symptoms  : 

1.  The  breasts  are  usually  enlarged  as  in  normal  pregnancy,  though 
this  is  not  a  constant  sign. 

2.  Amenorrhea  is  not  constant.     Hemorrhage  from  the  uterus  may 


DISEASES  AND   EVJURIES   OF  FEMALE    GENERATIVE    ORGANS.     769 

recur  at  irregular  intervals,  and,  when  accompanied  by  the  expulsion 
of  shreds  of  decidua,  is  a  most  characteristic  symptom. 

3.  The  uterus  enlarges  as  in  normal  pregnancy  up  to  about  the 
third  month,  and  the  os  is  soft  and  patulous. 

4.  When  pregnancy  has  been  suspected  and  symptoms  of  internal 
hemorrhage  suddenly  develop,  it  is  altogether  probable  that  the  gesta- 
tion-sac has  ruptured.  The  fetus  may  be  palpated  as  a  soft,  irregular 
mass  lying  to  one  side  and  behind  the  uterus.  When  the  fetus  has 
become  developed  it  is  sometimes  possible  to  recognize  the  head  and 
extremities  by  palpation. 

5.  The  pre-existence  of  salpingitis  and  a  long  period  of  sterility  is 
strongly  indicative  of  ectopic  gestation.  In  the  experience  of  Dr.  Joseph 
Price  rupture  of  ectopic  gestation-cysts  occurs  with  much  greater 
frequency  during  the  summer  months  than  during  any  other  period  of 
the  year,  and  with  noteworthy  frequency  in  women  in  whom  lactation 
is  prolonged  either  for  the  purpose  of  averting  pregnancy  or  from  other 
cause. 

Ectopic  gestation  at  term  is  manifested  by  characteristic  labor-pains, 
dilatation  of  the  os,  hemorrhage  from  the  uterus,  and  often  expulsion 
of  the  decidual  membrane.  These  pains  may  continue  for  several  days, 
and  the  breasts  may  secrete  milk  for  two  or  three  weeks.  All  these 
symptoms  may  disappear  and  the  tumor  gradually  diminish  in  size 
from  the  absorption  of  the  liquor  amnii  and  mummification  of  the  fetus. 
Again,  the  fetus  may  macerate,  suppurate,  or  become  gangrenous,  and 
either  cause  general  peritonitis,  or  its  remains  may  be  discharged 
through  the  groin,  vagina,  bladder,  or  rectum. 

Diagnosis. — Prior  to  the  rupture  of  the  pregnant  tube  there  is  often 
nothing  to  suggest  pregnancy.  However,  a  diagnosis  is  sometimes 
arrived  at  through  an  examination  made  because  of  the  suspicion  of 
pregnancy  on  the  part  of  the  patient  or  because  of  pain  in  the  iliac 
fossae.  When  the  tube  is  found  distended  and  boggy  we  should  alwa}-s 
think  of  the  possibility  of  ectopic  gestation,  and  where  there  are  irregu- 
lar symptoms  of  pregnancy,  with  the  uterus  slightly  enlarged  and  the 
cervix  soft,  the  presence  of  a  distended  tube  is  highly  suspicious  of 
tubal  pregnancy. 

The  expulsion  of  the  decidua,  accompanied  by  hemorrhage,  is  an 
important  symptom,  and  must  be  differentiated  from  an  early  uterine 
abortion  and  from  membranous  dysmenorrhea.  The  diagnosis  of  rup- 
ture of  the  tubal  sac  may  be  made  where  the  previous  history  of 
amenorrhea  and  more  or  less  definite  signs  of  pregnancy  are  followed 
by  the  appearance  of  a  sudden  pain  in  the  region  of  the  tube,  followed 
by  collapse.  The  diagnosis  subsequent  to  the  rupture  will  be  made  by 
the  above  history,  plus  finding  a  pelvic  hematocele  or  hematoma. 

Differential  Diagnosis. — Pelvic  Jicmatocelc  or  hematoma  due  to 
ectopic  gestation,  and  that  due  to  other  causes,  cannot  be  differentiated 
unless  the  history  points  directly  to  this  cause  or  the  fetal  remains  can 
be  found  in  the  blood-mass.  So  frequently  is  ectopic  gestation  the 
cause  of  hematosalpinx  that  we  are  quite  justified  in  ascribing  it  as  the 
cause  where  no  other  can  be  found. 

Tubal  pregnancy  must  be  differentiated  from  a  tube  distended  zvith 
pus  a?id  serum.  Prior  to  the  rupture  the  symptoms  and  physical  signs 
49 


770  SURGICAL    DIAGNOSIS  AND    TREATMENT. 

may  be  identical,  as  they  also  are  at  the  time  of  the  rupture.  Here 
the  history  of  previous  symptoms  of  pregnancy  will  often  suffice  to 
make  a  diagnosis.  After  the  effects  of  the  rupture  have  subsided  the 
subsequent  course  differs  more  widely. 

In  ruptured  tubal  pregnancy  the  temperature  is  at  first  subnormal, 
and  then  slowly  rises,  while  in  ruptured  pyosalpinx  the  temperature 
rises  rapidly.  In  the  former  condition  there  are  symptoms  of  internal 
hemorrhage,  the  pain  is  of  limited  duration,  and  the  general  symptoms 
of  sepsis  are  not  marked.  In  ruptured  pyosalpinx  there  are  no  signs 
of  internal  hemorrhage,  the  pain  is  prolonged,  the  pulse  becomes  rapid 
and  weak,  and  general  symptoms  of  sepsis  ensue. 

Ovaria?i  tinnors  are  to  be  excluded  by  the  menstrual  history  and 
the  signs  of  pregnancy. 

Subserous  fibroids  of  the  uterus  are  sometimes  mistaken  for  a  gesta- 
tion-sac. The  previous  history  of  increased  menstruation,  the  slow 
development,  the  absence  of  signs  of  pregnancy,  and  the  firm  consist- 
ency and  close  connection  of  the  growth  with  the  uterus  will  aid  in 
making  a  diagnosis. 

Treatment. — Electricity  has  been  recommended  as  a  means  of  de- 
stroying the  life  of  the  fetus  before  the  tube  has  ruptured,  with  the 
expectation  that  the  fetus  will  be  absorbed.  This  procedure  must  be 
condemned.  Nothing  short  of  the  remov^al  of  the  gestation-sac  is  indi- 
cated. At  the  time  of  rupture  of  the  sac,  unless  there  is  every  evidence 
of  extra-peritoneal  hemorrhage,  the  indication  is  imperative  for  imme- 
diate abdominal  section. 

After  the  gestation-sac  has  ruptured  and  the  symptoms  of  shock 
and  internal  hemorrhage  have  subsided  the  patient  may  survive  and 
the  condition  be  palliated  for  days,  weeks,  and  months  without  surgical 
interference.  The  indication,  however,  is  to  operate  on  all  intra-perito- 
neal  cases  at  the  earliest  possible  moment  by  abdominal  section, 
removing  all  blood-clots,  irrigating,  removing  the  gestation-sac,  and 
draining. 

Where  the  sac  has  ruptured  between  the  broad  ligaments  the  mass 
is  to  be  removed  by  way  of  the  vagina ;  the  pelvic  cavity  is  irrigated 
and  drained.  This,  however,  can  only  be  done  in  the  early  period  of 
gestation ;  after  the  third  month  the  abdominal  route  must  be  selected. 
As  late  as  the  fourth  month  the  embryo,  tube,  ovary,  placenta,  and 
adjacent  portions  of  the  broad  ligament  can  be  removed  in  toto,  but 
later  than  the  fourth  month  the  placenta  has  assumed  such  proportions 
and  has  become  so  firmly  adherent  to  its  point  of  attachment  that  it 
must  be  dealt  with  separately  from  the  gestation-sac.  In  the  treatment 
of  the  gestation-sac  no  attempt  should  be  made  to  extirpate  it,  because 
of  the  danger  of  bleeding  and  the  injury  to  the  bowel  and  ureters, 
which  are  often  firmly  adherent.  The  sac  should  be  opened  and  emp- 
tied of  its  contents,  then  stitched  to  the  abdominal  incision,  and  packed 
with  gauze.  J.  Bland  Sutton  formulates  the  treatment  of  the  placenta 
as  follows : 

1.  "  When  the  placenta  is  situated  above  the  fetus  it  is  good  practice 
to  attempt  its  removal  with  the  fetus. 

2.  "  In  some  instances  the  placenta  becomes  detached  in  the  course 
of  the  operation  and  leaves  no  choice. 


THE   X-RAYS  IN  SURGICAL   DIAGNOSIS.  JJl 

3.  "  When  the  placenta  is  below  the  fetus  it  may  be  left. 

4.  "  Should  the  placenta  be  left,  the  sac  closed,  and  symptoms  of 
suppuration  occur,  then  the  wound  must  be  reopened  and  the  placenta 
removed. 

5.  "  If  the  fetus  dies  before  the  operation  is  attempted,  the  placenta 
can  be  removed  without  risk  of  hemorrhage." 

It  is  thus  seen  that  the  operation  for  tubal  pregnancy  after  the  fourth 
month  is  fraught  with  great  dangers.  This  emphasizes  the  importance 
of  early  operative  interference.  No  time  should  be  lost  in  waiting  for 
the  period  of  viability  in  case  the  child  continues  to  live  after  the  rup- 
ture of  the  gestation-sac.  The  added  hazards  to  the  life  of  the  mother 
are  too  great  to  justify  the  almost  hopeless  endeavor  to  save  the  life  of 
the  child.  The  indication  is  for  immediate  operative  interference  as 
soon  as  the  condition  is  recognized. 


CHAPTER    XVII. 
THE  X=  (OR   RONTQEN)  RAYS    IN   SURGICAL   DIAGNOSIS. 

A  NEW  chapter  in  surgery  was  begun  when,  on  the  8th  da\'  of  De- 
cember, 1895,  Prof  Rontgen  of  Wurzburg,  Germany,  announced  his 
discovery  that  certain  rays  of  light  could  be  made  to  pass  through 
objects  hitherto  considered  opaque.  For  want  of  a  name,  he  let  x 
represent  this  unknown  quantity,  this  new  manifestation  of  energy,  and 
to  the  present  time  it  is  known  as  the  x-  or  Rontgen  ray.  The  scientific 
world  was  startled  and  amazed  when  photographs  of  the  human  hand 
showed  that  light  penetrated  the  soft  parts,  throwing  only  a  faint 
shadow,  while  the  bones,  resisting  the  passage  of  these  mysterious 
rays,  stood  out  clear  and  definite,  a  perfect  image  of  the  bony  skeleton. 
Metallic  substances  were  shown  to  be  impervious  to  the  rays,  and  when 
it  happened  that  bullets,  needles,  or  buckshot  were  lodged  in  the  tissues, 
the  photograph — or  skiagraph,  as  it  came  to  be  called — showed  the 
dark  shadow  of  the  object  and  revealed  its  position  with  perfect 
accuracy. 

Like  many  other  important  discoveries,  skiagraphy  was  arrived  at 
step  by  step.  The  first  step  was  taken  by  Maxwell  when  he  pro- 
pounded his  theory  regarding  light.  The  ether  is  the  name  applied  to 
the  subtle  fluid  which  pervades  all  bodies,  liquid  or  solid,  and  occupies 
the  boundless  space  between  the  stars.  Maxwell's  theory  is  that  waves 
of  light  are  identical  with  electro-magnetic  disturbances  in  ether. 

In  1879,  William  Crookes  published  the  results  of  his  wonderful 
experiments  upon  what  he  called  the  radiant  or  fourth  state  of  matter. 
Three  states  of  matter  were  familiar  to  every  one — namely,  solid, 
liquid,  and  gaseous,  but  this  fourth  state  was  something  new.  Michael 
Faraday  had  worked  in  the  same  direction,  and  had  expressed  his 
belief  that  there  existed  a  state  of  matter  in  which  the  molecules  were 
relatively  as  far  apart  as  compared  with  those  of  a  gas  as  the  molecules 
of  a  gas  were  as  compared  with  those  of  a  liquid.     What  Faraday 


']'J2  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

suggested,  Crookes  demonstrated  by  the  aid  of  his  now  world-renowned 
tubes. 

The  terms  a)iodc  and  cathode  were  employed  by  Faraday  to  designate 
the  conductor  terminals  by  which  a  current  enters  and  leaves  an  elec- 
trolytic cell — that  is  to  say,  a  cell  in  which  chemical  changes  in  the 
fluid  are  produced  by  the  passage  through  it  of  an  electric  current. 
The  element  from  which  the  current  passed  into  the  electrolyte  was 
designated  anode,  while  cathode  was  the  name  applied  to  the  element 
to  which  the  current  passed  from  the  electrolyte.  The  effect  of  electric 
discharges  through  rarefied  gases  was  also  studied  by  him,  and  Geiss- 
ler,  following  up  his  researches,  was  at  last  able  to  produce  from  the 
Geissler  tubes  the  startling  and  beautiful  effects  now  familiar  to  all. 
The  results  observed  at  the  anode  in  rarefied  gases  differed  from  those 
seen  at  the  cathode.  At  the  cathode  appeared  a  beautiful  bluish  light, 
while  the  balance  of  the  tube,  including  the  space  about  the  anode, 
presented  a  general  and  diffusive  glow.  One  of  the  effects  of  the 
cathode  was  the  production  of  fluorescence  or  phosphorescence,  and  it 
was  even  further  noticed  that  the  influence  from  the  cathode  moved  in 
straight  lines  ;  thus  the  term  catJiodic  rays  came  into  use  and  the 
cathode   became    a  central  point  of  interest  (Morton  and  Hammer). 

Crookes  came  to  the  conclusion  that  electrified  particles  were  pro- 
jected in  straight  lines  from  the  cathode.  In  the  air  of  the  tube 
exhausted  to  one-millionth  of  an  atmosphere,  and  thus  reduced  to  the 
radiant  or  fourth  state  of  matter,  the  molecules  were  so  far  apart  that 
these  electrified  particles  were  capable  of  passing  with  great  .speed  in  a 
straight  line,  and  bombarded  the  opposite  side  of  the  tube.  At  the 
same  time  the  glass  became  fluorescent. 

Hertz  took  the  next  step  by  proving  that  electro-magnetic  dis- 
turbances in  ether  possessed  many  of  the  properties  of  light,  as  refrac- 
tion, reflection,  dispersion,  and  polarization.  He  took  a  Crookes  tube 
— which  is  nothing  more  or  less  than  a  glass  tube  of  any  shape  from 
which  the  air  has  been  exhausted — and  found  that  the  cathode  rays  in 
passing  through  the  tube  were  capable  also  of  passing  through  opaque 
substances  tvithiii  the  tube.  This  was  in  1891,  and  shortly  afterward 
Hertz  died.  Paul  Lenard  took  up  the  investigation  where  Hertz,  his 
preceptor,  laid  it  down,  and  two  years  afterward  discovered  that  the 
rays  passed  through  opaque  objects  after  leaving  the  tube,  and  in  1893 
made  the  remarkable  announcement  that  he  had  obtained  photographs 
through  opaque  substances  by  means  of  these  rays.  Strange  to  say, 
his  statement  received  little  attention.  The  final  step  was  taken  when 
Rontgen,  on  the  8th  of  November,  1895,  while  experimenting  with  a 
Crookes  tube  covered  with  a  shield  of  black  cardboard,  noticed  that  a 
piece  of  barium-platinum-cyanide  became  phosphorescent.  He  worked 
on,  and  found  that  the  rays  affected  photographic  plates  in  the  same 
way  as  light  does,  but,  unlike  light,  these  rays  cannot  be  reflected,  con- 
centrated, or  refracted  outside  the  tube  in  which  they  have  their  origin. 

In  December,  1895,  Rontgen  laid  his  remarkable  communication 
before  the  Wurzburg  Physico-medical  Society  in  the  following  terms  : 

"  I.  If  we  pass  the  discharge  from  a  large  Ruhmkorff  coil  through  a 
Hittorf  or  a  sufficiently  exhau.sted  Lenard,  Crookes,  or  similar  appa- 
ratus, and  cover  the  tube  with  a  somewhat  closely  fitting  mantle  of  thin 


THE  X-RAYS  IN  SURGICAL   DIAGNOSIS.  773 

black  cardboard,  we  observe  in  a  perfectly  darkened  room  that  a  paper 
screen  washed  with  barium-platinum-cyanide  lights  up  brilliantly,  and 
fluoresces  equally  well  whether  the  treated  side  or  the  other  be  turned 
toward  the  discharge-tube.  Fluorescence  is  still  observable  two  meters 
away  from  the  apparatus.  It  is  easy  to  convince  one's  self  that  the 
cause  of  the  fluorescence  is  the  discharge  apparatus  and  nothing  else. 

"  2.  The  most  striking  feature  of  this  phenomenon  is  that  an  influence 
(Agens)  capable  of  exciting  brilliant  fluorescence  is  able  to  pass  through 
the  black  cardboard  cover,  which  transmits  none  of  the  ultra-violent 
rays  of  the  sun  or  of  the  electric  arc ;  and  one  immediately  inquires 
whether  other  bodies  possess  this  property.  It  is  soon  discovered  that 
all  bodies  are  transparent  to  this  influence,  but  in  very  different  degrees. 
A  few  examples  will  suffice  :  Paper  is  very  transparent ;  the  fluorescent 
screen  held  behind  a  bound  volume  of  1000  pages  still  lighted  up 
brightly ;  the  printer's  ink  offered  no  perceptible  obstacle.  Fluorescence 
was  also  noted  behind  two  packs  of  cards  ;  a  few  cards  held  between 
apparatus  and  screen  made  no  perceptible  difference.  A  single  sheet 
of  tin-foil  is  scarcely  noticeable ;  only  after  several  layers  have  been 
laid  on  top  of  each  other  is  a  shadow  clearly  visible  on  the  screen. 
Thick  blocks  of  wood  are  also  transparent ;  fir  planks  from  2  cm.  to  3 
cm.  thick  are  but  very  slightly  opaque.  A  film  of  aluminum  about  15 
mm.  thick  weakens  the  effect  very  considerably,  though  it  does  not 
entirely  destroy  the  fluorescence.  Several  centimeters  of  vulcanized 
India  rubber  let  the  rays  through.  Glass  plates  of  the  same  thickness 
behave  in  a  different  way  according  as  they  contain  lead  (flint  glass)  or 
not ;  the  former  are  much  less  transparent  than  the  latter.  If  the  hand 
is  held  between  the  discharge-tube  and  the  screen,  the  dark  shadow  of 
the  bones  is  visible  within  the  slightly  dark  shadow  of  the  hand.  Water, 
bisulphid  of  carbon,  and  various  other  liquids  behave  in  this  respect  as 
if  they  were  very  transparent.  I  was  not  able  to  determine  whether 
water  was  more  transparent  than  air.  Behind  plates  of  copper,  silver, 
lead,  gold,  platinum,  fluorescence  is  still  clearly  visible,  but  only  when 
the  plates  are  not  too  thick.  Platinum  0.2  mm.  thick  is  transparent ; 
silver  and  copper  sheets  may  be  decidedly  thicker.  Lead  1.5  thick  is  as 
good  as  opaque,  and  was  on  this  account  often  made  use  of.  A  wooden 
rod  20  by  20  mm.  cross-section,  painted  white  with  lead  paint  on  one 
side,  behaves  in  a  peculiar  manner.  When  it  is  interposed  between 
apparatus  and  screen,  it  has  almost  no  effect  when  the  -t'-rays  go 
through  the  rod  parallel  to  the  painted  side,  but  it  throws  a  dark 
shadow  if  the  rays  have  to  traverse  the  paint.  Very  similar  to  the 
metals  themselves  are  their  salts,  whether  solid  or  in  solution. 

"  3.  These  experimental  results  and  others  lead  to  the  conclusion 
that  the  transparency  of  different  substances  of  the  same  thickness  is 
mainly  conditioned  by  their  density ;  no  other  property  is  in  the  least 
comparable  with  this. 

"  The  following  experiments,  however,  show  that  density  is  not 
altogether  alone  in  its  influence :  I  experimented  on  the  transparency 
of  nearly  the  same  thickness  of  glass,  aluminum,  calc-spar,  and  quartz. 
The  density  of  these  substances  is  nearly  the  same,  and  yet  it  was 
quite  evident  that  the  spar  was  decidedly  less  transparent  than  the 
other  bodies,  which  were  very  much  like  each  other  in  their  behavior. 


774  SURGICAL   DIAGNOSIS  AXD    TREATMENT. 

I  have  not  observed  calc-spar  fluoresce  in  a  manner  comparable  with 
glass. 

"4.  With  increasing  thickness  all  bodies  become  less  transparent. 
In  order  to  find  a  law  connecting  transparency  with  thickness  I  made 
some  photographic  observations,  the  photographic  plate  being  partly 
covered  with  an  increasing  number  of  sheets  of  tin-foil. 

"  6.  The  fluorescence  of  barium-platino-cyanide  is  not  the  only 
recognizable  phenomenon  due  to  ,i'-rays.  It  may  be  observed,  first  of 
all,  that  other  bodies  fluoresce — for  example,  phosphorus,  calcium 
compounds,  uranium  glass,  ordinary  glass,  calc-spar,  rock  salt,  etc. 

"  Of  especial  interest  in  many  ways  is  the  fact  that  photographic  dry 
plates  show  themselves  susceptible  to  x-rays.  We  are  thus  in  a  posi- 
tion to  corroborate  many  phenomena  in  which  mistakes  are  ea.sy,  and 
I  have,  whenever  possible,  controlled  each  important  occular  observa- 
tion on  fluorescence  by  means  of  photography.  Owing  to  the  prop- 
erty possessed  by  the  rays  of  passing  almost  without  any  absorption 
through  thin  sheets  of  wood,  paper,  or  tin-foil,  we  take  the  impression 
on  the  photographic  plate  inside  the  camera  or  paper  cover  whilst  in  a 
well-lit  room.  In  former  days  this  property  of  the  ray  only  showed 
itself  in  the  necessity  under  which  we  lay  of  not  keeping  undeveloped 
plates,  wrapped  in  the  usual  paper  and  board,  for  any  length  of  time 
in  the  vicinity  of  discharge-tubes.  It  is  still  open  to  question  whether 
the  chemical  effect  on  the  silver  salts  of  photographic  plates  is  exer- 
cised directly  by  the  .r-rays.  It  is  possible  that  this  effect  is  due  to  the 
fluorescent  light,  which,  as  mentioned  above,  may  be  generated  on  the 
glass  plate  or  perhaps  on  the  layer  of  gelatin.  '  Films  '  may  be  used 
just  as  well  as  glass  plates. 

"  I  have  not  as  yet  experimentally  proved  that  the  .;r-rays  are  able 
to  cause  thermal  effects,  but  we  may  very  well  take  their  existence  as 
probable,  since  it  is  proved  that  the  fluorescent  phenomenon  alters  the 
properties  of  .I'-rays,  and  it  is  certain  that  all  the  incident  x-rays  do  not 
leave  the  bodies  as  such. 

"  The  retina  of  the  eye  is  not  susceptible  to  these  rays.  An  eye 
brought  close  up  to  the  discharge  apparatus  perceives  nothing,  although, 
according  to  experiments  made,  the  media  contained  in  the  eye  are 
fairly  transparent. 

"  7.  As  soon  as  I  had  determined  the  transparency  of  different  sub- 
stances of  various  thicknesses,  I  hastened  to  ascertain  how  the  x-rays 
behaved  when  passed  through  a  prism — whether  they  were  refracted 
or  not.  Water  and  carbon  disulphide  in  prisms  of  about  30°  refractive 
angle  showed  neither  with  the  fluorescing  screen  nor  with  the  photo- 
graphic plates  any  sign  of  refraction.  For  purposes  of  comparison  the 
refraction  of  light-rays  was  observed  under  the  same  conditions ;  the 
refracted  images  on  the  plate  were  respectively  about  10  mm.  and  20 
mm.  from  the  non-refracted  one.  With  an  aluminum  and  a  vulcanized 
rubber  prism  of  30°  angle  I  have  obtained  images  on  photographic 
plates  in  which  one  may  perhaps  see  refraction.  But  the  matter  is 
very  uncertain,  and  even  if  refraction  exists  it  is  so  small  that  the 
refractive  index  of  the  x-ray  for  the  above  materials  can  only  be,  at  the 
highest,  1.05.     Using  the  fluorescent  screen,  I  was  unable  to  discover 


THE  X-RAYS  IN  SURGICAL   DIAGNOSIS.  TJl 

any  refraction  at  all  in  the  case  of  the  aluminum  and  the  rubber 
prism. 

"  Researches  with  prismas  of  denser  metals  have  yielded,  up  to  now, 
no  certain  results,  on  account  of  the  small  transparency,  and  conse- 
quently lessened  intensity,  of  the  transmitted  ray. 

"  In  view  of  this  state  of  things,  and  the  importance  of  the  question 
whether  ;ir-rays  are  refracted  on  passing  from  one  medium  to  another, 
it  is  very  satisfactory  that  this  question  can  be  attacked  in  another  way 
than  by  means  of  prisms.  Finely  powdered  substances  in  sufficient 
thicknesses  only  allow  a  very  little  of  the  incident  light  to  pass  through, 
and  that  is  dispersed  by  refraction  and  reflection.  Now,  powdered  sub- 
stances are  quite  as  transparent  to  .f-rays  as  are  solid  bodies  of  equal 
mass.  Hence  it  is  proved  that  refraction  and  regular  reflection  do  not 
exist  to  a  noticeable  degree.  The  experiments  were  carried  out  with 
finely-powdered  rock  salt,  with  pulverulent  electrolytic  silver,  and  with 
the  zinc  powder  much  used  in  chemical  work.  In  no  case  was  any 
difference  observed  between  the  transparency  of  the  powdered  and  solid 
substance  either  when  using  the  fluorescent  screen  or  the  photographic 
plate. 

"  It  follows  from  what  has  been  said  that  the  a'-rays  cannot  be  con- 
centrated by  lenses ;  a  large  vulcanized  rubber  and  glass  lens  were 
without  influence.  The  shadow  of  a  round  rod  is  darker  in  the  middle 
than  at  the  edge ;  that  of  a  tube  filled  with  any  substance  more  trans- 
parent than  the  material  of  the  tube  is  lighter  in  the  middle  than  at 
the  edge. 

"  8.  The  question  of  the  reflection  of  the  ,r-rays  is  settled  in  one's 
mind  by  the  preceding  paragraphs,  and  no  appreciable  regular  reflec- 
tion of  the  rays  from  the  substances  experimented  with  need  be  looked 
for.  Other  investigations,  which  I  will  describe  here,  lead  to  the  same 
result.  Nevertheless,  an  observation  must  be  mentioned  which  at  first 
sight  appears  to  contradict  the  above  statement.  I  exposed  a  photo- 
graphic plate  to  the  ,r-rays,  protected  against  light  rays  by  black  paper, 
the  glass  side  being  directed  toward  the  discharge-tube.  The  sensitive 
layer  was  nearly  covered,  star-fashion,  with  blanks  of  platinum,  lead, 
zinc,  and  aluminum.  On  developing  the  negative  it  was  clearly  notice- 
able that  the  blackening  under  the  platinum,  lead,  and  especially  under 
the  zinc,  was  greater  than  in  other  places.  The  aluminum  had  exer- 
cised hardly  any  effect.  It  appeared,  therefore,  that  the  three  above- 
mentioned  metals  had  reflected  the  rays.  Nevertheless,  other  causes 
for  the  greater  blackening  were  thinkable,  and  in  order  to  make  sure 
I  made  a  second  experiment,  and  laid  a  piece  of  thiri  aluminum,  which 
is  opaque  to  ultra-violent  rays,  though  very  transparent  to  ;r-rays, 
.  between  the  sensitive  layers  and  the  metal  blanks.  As  again  much  the 
same  result  was  found,  a  reflection  of  A'-rays  by  the  above-mentioned 
metals  was  demonstrated.  But  if  we  connect  these  facts  with  the 
observation  that  powders  are  quite  as  transparent  as  solid  bodies,  and 
that,  moreover,  bodies  with  rough  surfaces  are,  in  regard  to  the  trans- 
mission of  ,r-rays,  as  well  as  in  the  experiment  just  described,  the  same 
as  polished  bodies,  one  comes  to  the  conclusion  that  regular  reflection, 
as  already  stated,  does  not  exist,  but  that  the  bodies  behaved  to  the  x- 
rays  as  muddy  media  do  to  light. 


776  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

"  Again,  as  I  could  discover  no  refraction  at  the  point  of  passage 
from  one  medium  to  another,  it  would  seem  as  if  the  A'-rays  went 
through  all  substances  at  the  same  si)eed,  and  that  in  a  medium  which 
is  ever}'\vhere,  and  in  which  the  material  particles  are  imbedded  ;  the 
particles  obstructing  the  propagation  of  the  a-rays  in  proportion  to  the 
density  of  the  bodies. 

"  9.  Hence  it  may  be  that  the  arrangement  of  the  particles  in  the 
bodies  influences  the  transparenc}- — that,  for  example,  equal  thick- 
nesses of  calc-spar  would  exhibit  different  transparencies  according  as 
the  ra\-s  were  in  the  direction  of  the  axis  or  at  right  angles  to  it. 
Researches  with  calc-spar  and  quartz  have  yielded  a  negative  result. 
"  10.  It  is  well  known  that  Lenard,  in  his  beautiful  investigation  on 
Hittorf  cathode  rays  passed  through  thin  aluminum-foil,  came  to  the 
conclusion  that  these  rays  were  actions  in  the  ether  and  that  they 
passed  diffusely  through  all  bodies.  I  have  been  able  to  say  the  same 
about  my  rays. 

"  In  his  last  work  Lenard  has  determined  the  absorption  coefficient  of 
various  bodies  for  cathode  rays,  and  among  other  things  for  air,  atmo- 
spheric pressure  at  4.1,  3.4,  3.1,  per  centimeter,  and  found  it  connected 
Avith  the  exhaustion  of  the  gas  contained  in  the  discharge  apparatus. 
In  order  to  estimate  the  discharge  pressure  by  the  spark-gap  method, 
I  used  in  my  researches  almost  always  the  same  exhaustion.  I  suc- 
ceeded with  a  Weber  photometer  (I  do  not  possess  a  better  one)  in 
comparing  the  intensity  of  the  light  of  my  fluorescing  screen  at  dis- 
tances of  about  100  mm.  and  200  mm.  from  the  discharge  apparatus, 
and  found  in  the  case  of  three  tests  agreeing  well  with  one  another 
that  it  varied  very  nearly  inversely  as  the  square  of  the  distance  of  the 
screen  from  the  discharge  apparatus.  Hence  the  air  absorbs  a  very 
much  smaller  fraction  of  the  ;i"-rays  than  of  the  cathode  rays.  This 
result  is  also  quite  in  agreement  with  the  result  previously  mentioned, 
that  the  fluorescing  light  was  still  observable  at  a  distance  of  two 
meters  from  the  discharge  apparatus. 

"  Other  bodies  behave  generally  like  air — that  is  to  say,  they  are 
more  transparent  for  x-rays  than  for  cathode  rays. 

"II.  A  further  noteworthy  difference  in  the  behavior  of  cathode  rays 
and  ,t--rays  consists  in  the  fact  that,  in  spite  of  many  attempts,  I  have 
not  succeeded,  even  with  vtvy  strong  magnetic  fields,  in  deflecting 
;r-rays  by  a  magnet.  The  magnetic  deflection  has  been  up  to  now  a 
characteristic  mark  of  the  cathode  rays  :  it  was,  indeed,  noticed  by 
Hertz  and  Lenard  that  there  were  different  kinds  of  cathode  rays, 
'  distinguishable  from  one  another  by  their  phosphorescing  powers, 
absorption,  and  magnetic  deflection,'  but  a  considerable  deflection  was 
nevertheless  observed  in  all  cases,  and  I  do  not  think  this  characteristic 
will  be  given  up  without  overwhelming  evidence. 

"  12.  After  experiments  bearing  specially  upon  this  question  it  is 
certain  that  the  spot  on  the  wall  of  the  discharge  apparatus  which 
fluoresces  most  decidedly  must  be  regarded  as  the  principal  point  of 
the  radiation  of  the  ;r-rays  in  all  directions.  The  ;i--rays  thus  start 
from  the  point  at  which,  according  to  the  researches  of  different  in- 
vestigators, the  cathode  rays  impinge  upon  the  wall  of  the  glass  tube. 
If  one  deflects  the  cathode  rays  within  the  apparatus  by  a  magnet,  it  is 


THE  X-RAYS  IN  SURGICAL    DIAGNOSIS.  'J'J'J 

found  that  the  x-rays  are  emitted  from  another  spot — that  is  to  say, 
from  the  new  termination  of  the  cathode  stream. 

"  On  this  account,  also,  the  ,i'-rays,  which  are  not  deflected,  cannot 
merely  be  unaltered  cathode  rays  passing  through  the  glass  wall.  The 
greater  density  of  the  glass  outside  the  discharge-tube  cannot,  accord- 
ing to  Lenard,  be  made  responsible  for  the  great  difference  in  the 
'  deflectability.' 

"  I  therefore  come  to  the  conclusion  that  the  .i--rays  are  not  identical 
with  the  cathode  rays,  but  that  they  are  generated  by  the  cathode  rays 
at  the  glass  wall  of  the  discharge  apparatus. 

"  13.  This  excitation  does  not  only  take  place  in  glass,  but  also  in 
aluminum,  as  I  was  able  to  ascertain  with  an  apparatus  closed  by  a 
sheet  of  aluminum  2  mm.  thick.  Other  substances  will  be  studied 
later  on. 

"  14.  The  justification  for  giving  the  name  of '  rays  '  to  the  influence 
emanating  from  the  wall  of  the  discharge  apparatus  depends  partly  on  the 
very  regular  shadows  which  they  form  when  one  interposes  more  or  less 
transparent  bodies  between  the  apparatus  and  the  fluorescing  screen  or 
photographic  plate.  Many  such  shadow  pictures,  the  formation  of  which 
possesses  a  special  charm,  I  have  observed — some  photographically. 
For  example,  I  possess  photographs  of  the  shadow  of  the  profile  of 
the  door  separating  the  room  in  which  was  the  discharge  apparatus 
from  the  room  in  which  was  the  photographic  plate ;  also  photographs 
of  the  shadows  of  the  bones  of  the  hand,  of  the  shadow  of  a  wire 
wound  on  a  wooden  spool,  of  a  weight  enclosed  in  a  small  box,  of  a 
compass  in  which  the  magnetic  needle  is  completely  surrounded  by 
metal,  of  a  piece  of  metal  the  lack  of  homogeneity  of  which  was 
brought  out  by  the  .:i'-rays,  etc. 

"  To  show  the  rectilinear  propagation  of  the  ;r-rays  there  is  a  pin- 
hole photograph  which  I  was  able  to  take  by  means  of  the  discharge 
apparatus  covered  with  black  paper.  The  image  is  weak,  but  un- 
mistakably correct. 

"15.  I  looked  very  carefulU'  for  interference  phenomena  with  ,r-rays, 
but,  unfortunately,  perhaps  only  on  account  of  the  small  intensity  of 
the  rays,  without  success. 

"  16.  Researches  to  determine  whether  electrostatic  forces  affect 
;i'-rays  in  any  way  have  been  begun,  but  are  not  completed. 

"  17.  If  we  ask  what  ,t'-rays,  which  certainly  cannot  be  cathode  rays, 
really  are,  we  are  led  at  first  sight,  owing  to  their  powerful  fluorescing 
and  chemical  properties,  to  think  of  ultra-violet  light.  But  we  im- 
mediately encounter  serious  objections.  If  x-rays  be  in  reality  ultra- 
violet light,  this  light  must  possess  the  following  characteristics  : 

"  {a)  It  must  show  no  perceptible  refraction  on  passing  from  air  into 
water,  bisulphid  of  carbon,  aluminum,  rock  salt,  glass,  zinc,  etc. 

"  {b)  It  must  not  be  regularly  reflected  to  any  appreciable  extent 
from  the  above  bodies. 

"  {c)  It  must  not  be  polarizable  by  the  usual  means. 

"  (^/)  Its  absorption  must  not  be  influenced  by  any  of  the  properties 
of  substances  to  the  same  extent  as  it  is  by  their  density. 

"  In  other  words,  we  must  assume  that  these  ultra-violet  rays  behave 
in  quite  a  different  manner  to  any  infra-red  visible  or  ultra-violent  rays 


JJ^  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

hitherto  known.  1  could  not  bring  myself  to  this  conclusion,  and  I 
have  therefore  sought  another  explanation. 

"  There  seems  at  least  some  connection  between  the  new  rays  and 
light-rays  in  the  shadow  pictures  and  in  the  fluorescing  and  chemical 
activity  of  both  kind  of  ra\'s.  Now,  it  has  been  long  known  that, 
besides  the  transverse  light  vibrations,  longitudinal  vibrations  might 
take  place  in  the  ether,  and,  according  to  the  view  of  the  different 
physicists,  must  take  place.  Certainly  their  existence  has  not,  up  till 
now,  been  made  evident,  and  their  properties  have  not  on  that  account 
been  experimentally  investigated. 

"  I\Iay  not  the  new  rays  be  due  to  longitudinal  vibrations  in  the 
ether  ?  I  must  admit  that  I  have  put  more  and  more  faith  in  this  idea 
in  the  course  of  my  research,  and  it  behooves  me,  therefore,  to  announce 
my  suspicion,  although  I  know  well  that  this  explanation  requires  further 
corroboration." 

Apparatus   required   for  a-^Ray  Work. 

The  apparatus  as  at  present  employed  consists  of  four  parts  : 

1.  The  battery  or  electric  machine.  To  supply  the  required  electric 
current  any  of  the  following  may  be  utilized  :  {a)  Static  electrical 
machines  ;  {p)  induction  coils  whose  primary  circuits  are  supplied  either 
with  continuous  or  alternating  electrical  currents  ;  (r)  Telsa  transformers, 
utilizing  oscillatory  electrical  currents. 

2.  The  Crookes  tube. 

3.  The  fluoroscope. 

Any  person  possessing  a  Holtz  machine  can  easily  connect  it 
with  a  Crookes  tube  at  small  expense  and  obtain  satisfactory  results 
in  .i--ray  work.  The  positive  and  negative  poles  must  first  be  deter- 
mined in  the  following  manner :  Operate  the  machine  in  the  dark  and 
observe  the  "  combs  "  or  "  collectors  "  on  each  side  of  the  revolving 
glass  disks.  At  those  combs  opposite  one  of  the  prime  conductors  a 
brilliant  "  brush-light "  discharge  will  be  observed  extending  from  the 
combs  along  the  surface  of  the  glass.  This  "  brush-discharge  "  is  posi- 
tive. The  discharge  at  the  negative  combs  appears  as  bright  star-like 
points  of  light.  That  prime  conductor  which  is  an  extension  of  the 
positive  combs  will  be,  by  induction,  a  negative  pole,  while  the  other 
prime  conductor  will  be,  by  induction,  a  positive  pole. 

Having  determined  these  polarities,  the  next  thing  is  to  connect  to 
each  prime  conductor  a  small  condenser  in  the  form  of  a  Leyden  jar. 
The  small  jars  are  the  best,  as  the  larger  ones  are  likely  to  crack  the 
glass  of  the  Crookes  tube. 

The  Leyden  jars  are  connected  to  the  prime  conductors  by  the 
internal  armatures.  The  external  armatures  are  connected  to  the 
Crookes  tube.  The  positive  prime  conductor,  as  previously  deter- 
mined, being  connected  to  the  internal  armature  of  one  Leyden  jar,  will 
induce  a  negative  charge  in  the  external  armature  of  the  same  jar. 
This,  therefore,  becomes  a  negative  pole  or  cathode,  and  the  source  of 
the  cathodic  stream  from  which  are  produced  the  .r-rays.  The  exter- 
nal armature  of  the  other  jar  becomes  the  anode  or  positive  pole.^ 
1  Morton  and  Hammer :  The  x-Ray,  pp.  80,  81. 


THE   X-RAYS  IN  SURGICAL   DIAGNOSIS. 


779 


Fig.  -323  illustrates  the  manner  of  connecting  a  Crookes  tube  to  a 
Holtz  machine. 

By  means  of  Tesla  transformers  ,i'-rays  of  great  power  may  be  ob- 
tained, and  by  the  more  elaborate  apparatus  the  photographic  plate 
has  been  affected  at  a  distance  of  forty  feet. 

Up  to  the  present  time  the  formula  of  Tesla  is  the  best  that  has 
been  introduced,  and  follows  the  principle  that  the  highest  efficacy  of 
the  rays  depends  upon  the  three  following  factors  :  high  voltage,  low 
amperage,  and  frequent  oscillations.  Dr.  Trouton  has  estimated  that  the 
duration  of  .r-radiation  at  each  spark  ranges  from  yo 0 0 0  ^^  soo  o^  ^ 
second.  Spark  coils  or  Holtz  machines  are  objectionable  as  ray- 
producers,  since  the  period  of  the  spark  is  much  longer  than  the  period 
of  radiation.  In  the  apparatus  constructed  upon  Telsa's  formula  by 
the  consumption  of  about  three  amperes  and  no  volts  a  voltage  of 
about  3,000,000  can  be  obtained,  and  a  frequency  of  about  400,000  a 


Sccfion  of 
Ley  den  Jar 
Fig.  323. —  Manner  of  connecting  a  Crookes  tube  to  a  Holtz  machine. 

minute,  or  66,666  a  second.  The  time  of  exposure  is  also  much 
lessened  by  the  use  of  Tesla's  formula,  being  only  eight  or  ten  minutes 
for  any  part  of  the  body,  instead  of  one  or  two  hours,  as  formerly. 
For  the  hands  and  feet  the  exposure  is  practically  instantaneous. 

For  further  information  on  this  subject  the  reader  is  referred  to  The 
x-Ray,  or  the  Photography  of  the  Invisible,  by  Dr.  Morton  and  Mr. 
Hammer. 

The  fluoroscope  was  invented  by  Edison,  and  is  an  invaluable  in- 
strument in  ;r-ray  examinations.  Rontgen  found  that  fluorescent  sub- 
jects were  excited  by  the  ,i--ray,  and  Salvioni  devised  a  tube  having  at 
one  end  a  pasteboard  cover  coated  with  fine  crystals  of  platino-cyanide 
of  barium,  and  at  the  other  an  eye-piece  through  which  the  operator 
could  view  the  shadow  cast  upon  the  fluorescent  screen  by  the  inter- 
vention of  the  opaque  object  between  it  and  the  Crookes  tube. 

Edison,  after  experimenting  with  eighteen  hundred  different  sub- 
stances, found  that  tungstate  of  calcium  had  better  fluorescent  qualities 
than  platino-cyanide  of  barium,  and  adopted  a  large  camera  or  dark 
chamber  in  the  form  of  a  stereopticon,  which  allowed  the  operator  to 
use  both  eyes  at    a  convenient  distance  from  the  screen. 

By  means  of  the  fluoroscope  the  operator  can  determine  whether 
.r-rays  are  being  produced  or  not  in  the  Crookes  tube.  He  can  also 
make  a  rapid  inspection  of  the  parts  under  examination,  and  from  as 
many  different  positions  as  necessary,  before  resorting  to  the  photo- 
graphic plate  for  a  permanent  record. 


78o  SURGICAL   DIAGNOSIS  AND    TREATMENT. 

Uses   of  the   j^-Rays. 

1.  The  Study  of  AnatoDiy. — The  liuman  skeleton,  no  matter  how 
carefully  mounted,  gives  an  imperfect  idea  of  the  true  relations  of  the 
bones  to  one  another.  Under  the  ,r-rays  these  relations  are  perfectly 
represented;  the  junction  of  epiphysis  with  bone  and  the  centers  of 
ossification  are  clearly  shown.  Fig.  324  shows  the  arteries  of  a  dead 
infant ;  the  vessels  were  injected  with  plaster  of  Paris  through  the 
umbilical  vein. 

Prof  Diakonof  suggests  that  structures  such  as  arteries,  veins,  and 
bronchioles  may  be  injected  with  mercury  on  account  of  the  ease  with 
w^hich  it  can  be  manipulated,  and  the  fact  that  the  same  injecting  fluid 
can  be  used  over  and  over  again.  Two  sets  of  vessels  in  the  same 
organ  may  be  injected  simultaneously — one  set  with  mercury,  and  the 
other  with  a  material  still  more  opaque.  He  recommends  the  follow- 
ing mixtute  :  gypsum,  cinnabar,  and  red  lead,  20  parts  each;  flour,  10 
parts ;  add  enough  water  to  make  the  mixture  sufficiently  fluid  to  flow 
into  the  smallest  vessels.  This  shows  a  very  dark  shadow  in  the 
skiagraph,  in  strong  contrast  to  the  shadow  thrown  by  mercur>'. 

2.  F^'actiircs  and  Dislocations. — The  position  of  the  fragments  in  a 
recent  fracture,  the  condition  of  an  ununited  fracture,  and  the  question 
of  the  existence  or  non-existence  of  a  dislocation  can  be  settled  by  the 
jr-rays. 

3.  Diseases  of  Bones. — In  Fig.  325  is  represented  a  tubercular  focus 
in  the  os  calcis.  In  this  case  the  ;i"-rays  settled  the  diagnosis  between 
sarcoma   and  tubercular  osteitis. 

4.  Tlie  Detection  of  Foreign  Bodies. — The  first  and  most  frequent 
application  of  Rontgen's  discovery  was  to  the  detection  of  foreign 
bodies  in  the  tissues.  Fig.  326  represents  the  hand  and  wrist  of  a 
colored  girl  w^ho  seven  years  previously  received  a  charge  of  buckshot. 
In  Fig.  327  is  seen  the  knee  of  a  man  containing  a  bullet.  This  was 
supposed  to  be  a  case  of  rheumatism  until  the  radiograph  was  taken, 
and  then  the  fact  was  recalled  that  the  patient  had  received  a  bullet  in 
the  thigh  seven  months  previously.  The  missile  took  a  downward 
course,  and  most  unexpectedly  found  its  way  to  the  knee-joint,  as 
shown  in  the  picture.  A  toy  whistle  in  the  esophagus  of  a  little  girl  is 
represented  in  Fig.  328.  It  had  been  in  that  position  nine  days  when 
Dr.  Law  removed  it  with  esophageal  forceps. 

5.  Mineral  concretions,  such  as  renal  and  vesical  calculi,  are  im- 
pervious to  the  .I'-rays,  and  with  increased  dexterity  on  the  part  of 
examiners  we  may  shortly  expect  much  light  in  the  diagnosis  of  these 
bodies.  Calcareous  and  atheromatous  deposits  in  arteries  can  also  be 
determined  with  accuracy.  Dr.  Kiimmel  of  Hamburg  has  shown  that 
in  arterial  sclerosis  the  sclerosed  arteries  become  visible  as  black  stripes 
on  the  skiagram.  So  far,  gall-stones  have  not  been  seen  by  the  a-rays. 
Laurie  and  Leon  by  experiment  hav^e  shown  that  urinary  calculi  com- 
posed of  oxalate  or  phosphate  of  lime  are  more  opaque  than  bone, 
uric-acid  calculi  of  almost  the  same  opacity,  and  gall-stones  very  slightly 
more  opaque  than  flesh. 

Potain  and  Cerbanisco  claimed  to  make  a  differential  diagnosis 
between  deposits  of  gout  and  rheumatism  by  the  aid  of  -t'-rays.     Ac- 


Fig.  324.— Arteries  of  an  infant  (pliotograph  by  Dr.  Artlnir  Ayer  Law). 


Fig.  325.— Tubercular  focus  in  the  os  calcis  (photograpli  by  Dr.  .Arthur  .Vyer  Law). 


>  ^ 

?  p 

I— I  u 


Fig.  328. — Toy  whistle  in  the  esophagus  (photograpli  by  Dr.  Artluir  Ayer  Law). 


THE  X-RA  YS  IN  SURGICAL  DIAGNOSIS.  78 1 

cording  to  these  observ^ers,  the  former  show  a  translucent  central  part 
limited  by  a  narrow  dark  border,  which  is  again  enclosed  in  a  wider 
opaque  area.  This  central  clear  portion  is  absent  in  rheumatic  thicken- 
ing. It  is  attributed  to  the  greater  permeabilit)-  to  the  rays  of  urate 
of  soda  as  compared  with  rheumatic  deposits,  and  also  with  the  nor- 
mal bone  salts — a  conclusion  which  they  have  confirmed  by  further 
independent  observations. 

6.  Under  the  fluoroscope  the  soft  tissues  can  be  studied.  Thus,  the 
heart  casting  a  darker  shadow  than  the  surrounding  parts,  its  pulsations 
can  be  observed  as  a  wave  of  shadow  changing  shape,  while  another 
shadow  representing  the  liver  is  seen  to  rise  and  fall  with  respiration. 


INDEX. 


Abbe's  operation,  198 

rings,  248 
Abdomen,  contusions  of,  207 
diseases  and  injuries  of,  201 
enterectomy  in  wounds  of,  213 
examination  of,  201 
gunshot  wounds  of,  208 
incised  wounds  of,  208 
laparotomy  in  punctured  wounds  of,  21 1 
non-penetrating  wounds  of,  208 
omental  grafting  in  wounds  of,  214 
penetrating  wounds  of,  209 
search  for  perforations  in,  212 
stab-wounds  of,  208 
treatment  after  operation,  214 
wounds  of,  208 
Abdominal  aorta,  aneurysm  of,  43 
cavity,  irrigation  of,  214 
drainage,  214 
hysterectomy,  742,  756 
nephrectomy,  359 
section,  206,  211,  732 

adhesions  found  in,  247 

after-treatment  in,  214 

arrest  of  hemorrhage,  212 

closure  and  dressing  of  wound  in, 
214 

for  diagnosis,  206 

for  diseases  of  female  generative  or- 
gans, 730 

drainage  in,  214 

incision  for,  212 

preparation  of  patient  in,  212 
Abductors  of  larynx,  paralysis  of,  633 
Abscess,  of  antrum,  589 
appendicular,  274 
of  bone,  94 
of  brain,  487 

initiatory  stage,  488 

operative  treatment,  493 

second  stage,  489 

third  stage,  491 

treatment  of,  492 
of  breast,  676 
cerebellar,  491,  494 
cerebral,  487 

from  ear  diseases,  486,  488,  494 


Abscess,  cold,  152 

dorsal,  534 

hepatic,  292 

of  hip-joint,  155 

ischio-rectal,  332 

of  larynx,  617 

of  liver,  292 

lumbar,  534 

nephritic,  360 

of  pancreas,  315 

perinephric,  360 

peri  nephritic,  360 

perityphlitic,  274 

of  prostate,  417 

psoas,  534 

of  rectum,  332 

retropharyngeal,  195 
treatment  of,  196 

spinal,  534 

of  spleen,  319 
Acetabulum,  fracture  of,  116 
Acromegaly,  105 
Acromion  process,  fracture  of,  65 
Actinomycosis,  97 

Adam's  operation  for  Dupuytren's  con- 
traction, no 
Adductors  of  larynx,  paralysis  of,  634 
Adenitis,  syphilitic,  671 

tubercular,  671 
Adenoma  of  breast,  678 
Adenomata,  668 
Adeno-sarcoma  of  breast,  679 
Agraphia,  499 

Air-passages,  foreign  bodies  in,  605 
Alexander's  operation,  712 
Alexia,  471,  499 
Amenorrhea,  704 
Amputation  after  injury,  88 

indications  for,  88 
Anastomosis,  intestinal,  247 
Anderson's  method  of  tendon-lengthen- 
ing, 107 
Anel's  operation  in  aneurysm,  34 
Anesthesia  in  aneurysm,  40 
Aneurysm,  30 

abdominal,  43 

Anel's  operation  for,  34 

7S3 


784 


INDEX. 


Aneurysm,  Antyllus's  operation  for,  35 

aortic,  35 

of  arch  of  aorta,  35 
ascending,  36 
descending,  38 
transverse,  37 

arterio-venous,  48 

axillary,  42 

Brasdor's  operation  foi',  35 

of  carotid  artery,  41 

causes  of,  30 

cirsoid,  48 

classification  of,  30 

compression  in,  34 

diagnosis  of,  32 

dissecting,  31 

Esmarch's  bandage  in,  34 

false,  31 

femoral,  46 

fusiform,  31 

galvano-puncture  in,  40 

Hunterian  operation  for,  34 

idiopathic,  30 

iliac,  44 

innominate,  39 

Macevven's  method  in,  40 

orbital  or  ophthalmic,  41 

popliteal,  46 

sacculated,  31 

subclavian,  42 

symptoms  of,  32 

traumatic,  30,  47 

treatment  of,  34 

true  sacculated,  31 

varicose,  48 

vertebral,  41 

Wardrop's  operation  for,  35 
Aneurysmal  varix,  48 
Angeiomata,  665 
Ankle,  examination  of,  140 
Ankle-joint  disease,  162 

tuberculosis  of,  162 
Anosmia,  606 
Antrum  of  Highmore,  588 
abscess  of,  589 
diseases  of,  588 
foreign  growths  in,  591 
injuries  of,  588 
Antyllus,  method  of,  in  aneurysm,  35 
Anus,  artificial,  245 
fissure  of,  337 
imperforate,  347 
prolapse  of,  327 
pruritus  of,  329 
Aorta,  abdominal,  aneurysm  of,  43 


Aphasia,  471 

Apoplexy,  differential  diagnosis  of,  472 

Appendicitis,  273 

after-treatment  of,  280 

causes  of,  274 

classification  of,  278 

diagnosis  of,  276 

etiology  of,  274 

indications  for  operation  in,  279 

McBurney's  plan  of  incising  abdomi- 
nal wall  in,  280 

obliterans,  279 

perforating,  278 

surgical  treatment  of,  279 

symptoms  of,  275 
Apraxia,  471 
Areas  of  brain,  456 
Arm,  cerebral  center  for,  458 
Arteries,  atheroma  of,  29 

calcification  of,  30 

compression  of,  27 

examination  of,  27 

inflammation  of,  29 

ligation  of,  28 

rupture  of  coats  of,  27 

special,  arrest  of  hemorrhage  in,  27 
compression  of,  28 

wounds  of,  27 
Arteritis,  29 

Artery  of  cerebral  hemorrhage,  472 
Artery  and  arteries,  laceration  of,  in  frac- 
ture, 56 

lenticulo-striate,  472 

middle  meningeal,  hemorrhage  from, 
472 

wounds  of,  27 
Arthritis,  148 

causes  of,  148 

chronic  rheumatoid,  164 

gonorrheal,  164 

gouty,  165 

neuropathic,  165 

pyemic,  151 

rheumatic,  164 

septic,  1 50 

suppurative,  150 

tubercular,  152 
Arthrotomy,  83 
Ascites,  203,  764 

Aspiration    in    over-distention    of    ven- 
tricles, 22 

in  paracentesis  thoracis,  23 
Atheroma,  29 
Atony  of  bladder,  381 
Atrophy  of  tongue,  180 


INDEX. 


785 


Balanitis,  426 

Barker's   operation  for  fractured  patella, 

83 
Bavarian  splint,  85 
Bichat,  fissure  of,  459 
Bigelow's   method   of  reducing   disloca- 
tions, 135 
Bladder,  atony  of,  381 

carcinoma  of,  405 

congenital  deformities  of,  427 

diseases  and  injuries  of,  375 

examination  of,  375 

exstrophy  of,  407 

fibromata  of,  405 

hernia  of,  409 

inflammation  of,  383 

myomata  of,  405 

papillomata  of,  404 

rupture  of,  378 

sacculation  of,  384 

sarcomata  of,  403 

stone  in,  386 

tumors  of,  404 

wounds  of,  377 
Bodies,  loose,  in  joints,  142 
Bone,  chondromata  of,  99 

diseases  of,  89 

fibromata  of,  100 

inflammation  of,  89 
chronic,  93 
septic,  91 

overgrowth  of,  98 

sarcomata  of,  loi 

tuberculosis  of,  94 

tumors  of,  98 
malignant,  loi 
Bone-chips,  decalcified,  247 
Bone-plates,  Senn's  decalcified,  247 
Bougies  a  boule,  435 

filiform  whalebone,  439 
Brain,  abscess  of,  478 

color  of,  477 

compression  of,  470 

concussion  of,  469 

examination  of,  477 

faradization  of,  for  determining  motor 
centers,  477 

foreign  bodies  in,  478 

gunshot  wounds  of,  478 

and  membranes,  injuries  of,  469 

motor  areas  of,  458 

operations  on,  478 

pulsation  of,  477 

topography  of,  455 

treatment  of,  after  operation,  478 
50 


Brain,  wounds  of,  478 
Branchial  cysts,  669 
Breast,  adeno-fibroma  of,  678 
adeno-sarcoma  of,  679 
cancer  of,  679 
cancer  en  cuirasse,  682 
carcinoma  of,  679 
medullary,  681 
scirrhous,  680 
operation  for,  681 

contraindications  for,  681 
Halsted's,  682 
soft,  681 
cysts  of,  678 

diseases  and  injuries  of,  675 
examination  of,  675 
inflammation  of,  676 
neuroses  of,  677 
sarcoma  of,  679 
tumors  of,  681 
malignant,  679 
treatment  of,  681 
Broca's  centre  of  speech,  459 
Bronchial  tubes,  640 

injuries  of,  640 
Bronchocele,  674 
Buck's  extension  apparatus,  80 
Bursae,  affections  of,  no 
Bursitis,  no 

Cachexia,  681 
Calcification  of  arteries,  30 
Calculus  of  prostate,  419 
renal,  354 
salivary,  179 
of  ureter,  373 
vesical,  386 
measuring,  392 
operative  treatment  of,  393 
preparatory  treatment  for   operation 

in,  396 
sounding  for,  388 
symptoms  of,  387 
treatment  of,  393 
Cancer  of  breast,  679 
chimney-sweep's,  447 
en  cuirasse,  682 
Cancerous  cachexia,  681 
Caput  succedaneum,  462 
Carcinoma  of  brain,  496 
of  breast,  679 
scirrhous,  680 

retraction  of  nipple  in,  680 
soft,  681 
of  cervix  uteri,  720 


786 


INDEX. 


Carcinoma,  diagnosis  of,  669 
of  intestine,  234 
of  larynx,  629 

diagnosis  of,  630 
of  nose,  564 
of   ovary,  760 
of  pancreas,  316 
of  prostate,  413 
of  stomacli,  220 
of  uterus,  753 
cause  of,  749 
of  cerv^ix,  749 

palliative    treatment    of    advanced 
cases,  751 
Carcinomata,  668 
Caries,  91 

Cartilages,  semilunar,  dislocation  of,  144 
Castration,  450 

for  hypertrophied  prostate,  415 
Catarrh,  572 
nasal,  572 
atrophic,  575 
hypertrophic,  572 
Celiotomy  for  acute  obstruction,  245 
Center,  cerebral,  for  arm,  458 
for  face,  458 
for  hearing,  460 
for  leg,  458 
for  smell,  460 
for  speech,  459 
auditory,  459 
visual,  459 
for  vision,  460 
Cephalhematoma,  462 
Cerebral  topography,  455 
Cervicitis,  719 

Cervix  uteri,  amputation  of,  722 
carcinoma  of,  749 
lacerations  of,  735 
tuberculosis  of,  734 
Chancre,  diagnosis  of,  649 
differential  diagnosis  of,  650 
hard,  649 

soft,  or  chancroid,  650 
of  tongue,  182 
Chancroid,  649 

treatment  of,  650 
Chapped  lips,  172 
Charcot's  disease,  165 
Chest,  contusions  of,  645 

effusion  into  pleural  cavity,  645 
wounds  of,  645 
Chiene's  method  for  finding  Rolandic  fis- 
sure, 460 
Chimney-sweep's  cancer,  447 


Cholecystectomy,  313 

Cholecyst-enterostomy,  310 

Cholecystotomy,  308 

Cholelithotomy  in  two  stages,  310 

Chondritis,  617 

Chondromata,  665 

Chorditis  tuberosa,  614 

Claw-hand,  554 

Cleft-palate,  174 

Cloaca,  93 

Cold  in  head,  570 

Colon,  distention  of,  with  fluids,  245 

tubage  of,  245 
Colostomy,  345 
Compound  fractures,  88 
Compression  for  aneurysm,  34 

of  brain,  470 

local,  471 

total,  470 
Concretions  of  tonsils,  194 
Concussion  of  brain,  469 
Contre-coup,  fractures  by,  52 
Contusions  of  joints,  11 1 

of  kidney,  349 
Coryza,  acute,  572 
Cracked  lips,  172 
Cracked-pot  sound  in  fissured  fracture  of 

skull,  466 
Curvature  of  spine,  525 
anterior,  530 
lateral,  525 
posterior,  529 
Cyrtometer,  Horsley's,  461 
Cystitis,  383 

treatment  of,  385 
Cystocele,  409 
Cystoscope  Leiter's,  391 
Cysts  of  breast,  678 

hydatid,  of  liver,  296 

of  kidney,  366 

of  liver,  296 

multilocular,  760 

of  ovary,  760 
dermoid,  760 

of  pancreas,  315 

papillomatous,  761 

of  tubes,  759 

tubo-ovarian,  761 

unilocular,  760 

Deformity,  silver-fork,  74 

Digestive  tract,  injuries  and  diseases  of, 

166 
Dilatation  of  stomach,  231 
of  urethra,  437 


nVDEX. 


7^7 


Diplopia  from  paralysis  of  fourth  nerve, 

481 
Dislocations,  114 
of  ankle,  140 
of  astragalus,  142 
of  carpal  bones  from  radius,  130 
carpo-metacarpal,  131 
causes  of,  114 
classification  of,  114 
of  clavicle,  120 
complications  of,  116 
compound,  117 
congenital,  114 
differential  diagnosis  of,  112 
of  elbow,  127 

old  unreduced,  130 
etiology  of,  114 
examination  of,  115 
of  femur,  134 

backward,  on  dorsum  ilii,  134 

forward,   136 

into  sciatic  notch,  134 
of  hip,  134 

congenital,  138 

diagnosis,  138 
of  humerus,  123 

incomplete,  114 
of  lower  jaw,  118 
of  knee,  139 

metacarpal  phalangeal,  131 
methods  of  reduction  of,  116 
old,  reduction  of,  117 
of  patella,  140 
pathological,  114 
of  phalanges,  131 
of  radius  alone,  127 
of  radius  and  ulna,  127 
reduction  of,  by  manipulation,  117 
of  semilunar  cartilages,  144 
of  shoulder,  123 

luxatio  erecta,  127 

old  unreduced,  treatment  of,  117 

reduction   of,  by   Kocher's   method, 
124 

treatment  of,  124 
of  sternum,  122 
subastragaloid,  142 
symptoms  of,  115 
traumatic,  114 
treatment  of,  1 16 
of  ulna  alone,  130 
of  wrist,  130 
Diverticula  of  esophagus,  196 
Dugas's  test,  67 
Duplay's  operation  for  hypospadias,  443 


Dupuytren's  contraction  of  fingers,  109 

splint,  87 
Dural  separator,  Horsley's,  477 
Dysmenorrhea,  706 

ECCHYMOSIS,  53 
Echinococcus,  296 
Edema  of  larynx,  614 
Elbow,  examination  of,  120 
Elbow-joint,  diseases  of,  163 
dislocation  of,  127 
tuberculosis  of,  163 
Elephantiasis  of  nose,  556 
Enchondroma  of  larynx,  625 
Enchondromata,  99 
Endocervicitis,  719 
Endometritis,  718 
Enterectomy,  252 

in  wounds  of  abdomen,  213 
Enterocele,  258 
Enterostomy,  244 
Enterotomy,  244 
Epididymitis,  429 
Epilepsy,  504 

idiopathic,  504 

Jacksonian,  504 

traumatic,  505 

trephining  for,  506 
Epiphysis  of  humerus,  separation  of,  68 
lower,  71 
upper,  54 
Epiplocele,  258 
Epispadias,  445 
Epistaxis,  564 
Epithelioma,  667 

of  nose,  567 

of  tongue,  182 
Epulis,  187 

Esmarch's  bandage  in  aneurysm,  34 
Esophageal  bougies,  198 
Esophagectomy,  199 
Esophagoscope,  198 
Esophagotomy,  199 
Esophagus,  dilatation  of,  198 

diseases  and  injuries  of,  196 

gastrotomy  in,  199 

malformations  of,  196 

operations  on,  189 

sacculation  of,  196 

stricture  of,  196 

malignant,  treatment  of,  198 
Esthesiometer,  538 
Estlander's  operation,  647 
Ethmoidal  sinuses,  594 
Examination  of  patients,  19 


788 


INDEX. 


Exostoses,  98 
Exstrophy  of  bladder,  437 
Extension  apparatus,  116 
External  genitalia,  691 
Extra-uterine  pregnancy,  727 
Extravasation  of  urine,  439 

Face,  cerebral  centre  for,  458 
Fallopian  tube,  anomalies  of,  698 

tuberculosis  of,  734 
False  passages,  422 
Fat-embolism,  55 
Fatty  tumors  of  scalp,  463 
Fecal  impaction,  255 

obstruction,  255 
Female  generative  organs,  767 
Fenger's  method  in  ureteral  stricture,  375 
Fever  after  fracture,  55 
Fibroids,  uterine,  738 
interstitial,  739 
submucous,  739 
subperitoneal,  739 
Fibromata,  664 

Fibromyomata,  electrolysis  in,  742 
ergot  in,  741 
extirpation  through  abdominal  incision, 

742 
morcellation  in,  742 
removal    of    uterine    appendages   for, 
742 
through  vagina,  742 
submucous,  739 
subserous,  of  tubes,  759 
Filiform  whalebone  bougies,  439 
Fingers,  Dupuytren's  contraction  of,  109 
Fissure  of  anus,  337 
of  Bichat,  460 

method  of  finding,  460 
of  Rolando,  460 

Chiene's  method  of  finding,  460 
of  Sylvius,  461 
Fistula  in  ano,  333 
blind,  335 
complete,  334 
gastric,  219 
horseshoe,  336 
incomplete,  334 
and  phthisis,  337 
Floating  kidney,  355 

liver,  298 
Fluhrer's  aluminum  probe,  483 
Foreign  bodies  in  air-passages,  596 

in  urethra,  423 
Fracture  or  fractures,  49 
of  acromion  process,  65 


Fracture  of  astragalus,  87 
Barton's,  75 
classification  of,  50 
of  clavicle,  60 
of  coccyx,  76 
CoUes',  74 
comminuted,  52 
complete,  51 
complications    and    consequences    of, 

55 
compound,  52,  88 
by  contre-coup,  52 
of  coracoid  process,  72 
of  coronoid  process,  72 
crepitus  in,  53 
deformity  in,  53 
diagnosis  of,  52 
displacements  in,  53 
evidence  of,  52 
of  femur,  77 

extra-capsular,  77 

intra-capsular,  'j'j 

lower  end  of,  81 

neck  of,  77 

shaft  of,  79 
of  fibula,  86 
of  great  trochanter,  77 
green-stick,  72 

of  hip,  measurement  in,  52,  78 
of  humerus,  65 

lower  end  of,  68 

shaft  of,  65 

upper  end  of,  66 

with  dislocation,  67 
of  hyoid  bone,  62 
of  ilium,  77 
immediate  causes  of,  52 
incomplete,  50 
by  indirect  violence,  52 
of  inferior  maxilla,  60 
intercondyloid,  51 
intra-articular,  51 
intra-capsular,  51 
of  ischium,  "]"] 
of  leg,  84 
of  lower  jaw,  60 
of  malar  bone,  59 
of  malleolus,  87 
of  metacarpal  bones,  75 
mobility  abnormal  in,  53 
by  muscular  action,  52 
of  nasal  bones,  58 
of  olecranon,  71 
of  patella,  82 

operative  measures  for,  82 


INDEX. 


789 


Fracture,  pathological,  80 
of  pelvis,  75 
of  phalanges,  75 
Pott's,  86 
of  pubes,  76 
of  radius,  lower  end  of,  74 

shaft  of,  73 

and  ulna,  72 

upper  end  of,  73 
of  ribs,  63 
of  sacrum,  76 
of  scapula,  64 
simple,  50 
of  skull,  465 

base  of,  467 

compound,  465,  467 

by  contre-coup,  465 

fissure  of  vault,  465 

inner  table  of,  466 

punctured,  467 

simple,  466 

vault  of,  465 
of  sternum,  63 
of  superior  maxilla,  5y 
symptoms  of,  53 
T-shaped,  69,  81 
of  tibia,  85 
toothed,  51 
transverse,  51 

of  ulna,  shaft  of,  V-shaped,  51 
Fragilitas  ossium,  96 
Frontal  sinus,  diseases  of,  592 

tumors  of,  593 
sinuses,  foreign  bodies  in,  593 

inflammation  of,  592 

injuries  of,  591 

Gall-bladder,  anatomy  of,  298,  314 

diagnosis  of  position  of,  303 

diseases  and  injuries  of,  298 

ducts  of,  309 

empyema  of,  314 

wounds  of,  313 
Gall-stones,  298 

diagnosis  of,  303 

pathological  changes  produced  by,  304 

surgical  treatment  of,  307 
Galvano-puncture  in  aneurysm,  40 
Ganglion,  109 

compound,  log 
Gastrectasia,  231 
Gastric  fistula,  219 
Gastro-enterostomy,  231 
Gastroscopy,  227 
Gastrostomy,  199 


Gastrostomy,  Ssabanejew-Frank's  opera- 
tion, igq 
Witzel's  method  of  performing,  199 
Generative  organs,  anomalies  of,  695 
diseases  of,  685 

methods  of  examination  of,  685 
positions  for  examination,  686 
Girdner's  telephonic  probe,  483 
Gleet,  433 

treatment  of,  433 
Glioma,  496 
Glottis,  spasm  of,  635 
Goiter,  674 
Gonorrhea,  425 
abortive,  430 
catarrhal,  429 

complications  of,  426 
chronic,  433 
irritative,  430 

symptoms  and    complications  of  first 
stage,  426 
second  stage,  428 
third  stage,  429 
treatment  of,  430 
Gonorrheal  rheumatism,  429 
Gouty  arthritis,  165 

Hare-lip,  166 

Head,  diseases  and  injuries  of,  455 

gunshot  wounds  of,  482 
Hearing,  cerebral  centre  for,  459 
Heart,  diseases  of,  22 

injuries  of,  24 

over-distention  of  ventricles,  22 

rupture  of,  24 

tapping  cavity  of,  22 

wounds  of,  24 
Hematocele,  453 

traumatic,  453 
Hematosalpinx,  726 

Hematuria  in  genito-urinary  diseases,  376 
Hemianopsia,  460 
Hemorrhage,  27 

in  abdominal  section,  arrest  of,  28,  206 

into  brain-substance,  473 

cerebral,  artery  of,  472 

extra-dural,  472 

intra-cranial,  472 
treatment  of,  473 

local  treatment  of,  28 

from  middle  meningeal,  472 

pancreatic,  315 

subarachnoid,  473 

subdural,  472 
Hemorrhoids,  323 


790 


INDEX. 


Hemorrhoids,  arterial,  324 

capillary,  324 

cutaneous,  323 

external,  323 

internal,  324 

treatment  of,  326 

venous,  323 
Hepatotomy,  295 
Heredity,  18 
Hermaphrodism,  695 
Hernia,  255 

Bassini's  method  of  radical  cure  of,  268 

of  bladder,  409 
causes  of,  256 

Championniere's    method    of    radical 
cure  of,  265 

congenital,  radical  cure  of,  261 

diagnosis  of,  259 

diaphragmatic,  273 

femoral,  259 

Halsted's  operation  for,  268 

incarcerated,  260 

inguinal,  257 

irreducible,  259 

of  Littre,  treatment  of,  261 

lumbar,  273 

Macewen's  operation  for,  267 

obturator,  273 

palliative  treatment  of,  270 

perineal,  273 

radical  cure  of,  263 

strangulated,  260 

differential  diagnosis  of,  261 

umbilical,  271 

varieties  of,  257 

ventral,  272 
Herniotomy,  262 
Hip-joint,  disease  of,  153 

symptoms  of  first  stage,  1 53 
of  second  stage,  153 
of  third  stage,  155 
treatment  of,  156 

examination  of,  131 

tuberculosis  of,  1 53 
Hodgen's  splint,  81 
Hodgkin's  disease,  672 
Hoffa's  appliance  for  curvature,  529 
Horsley's  cyrtometer,  461 

dural  separator,  477 
Housemaid's  knee,  1 10 
Hunterian  operation  for  aneurysm,  34 
Hydrated  testicle,  450 
Hydrocele,  451 

of  cord,  453 

incision  of,  452 


Hydrocele,  symptoms  of,  451 

tapping  of,  452 

treatment  of,  452 
Hydrogen  gas  in  intestinal  perforation, 

210 
Hydrogen-test  in  intestinal  injuries,  210 
Hydronephrosis,  363 
Hydrops  ventriculorum,  496 
Hydrosalpinx,  725 
Hyperosmia,  596 
Hypertrophy  of  lips,  172 

of  prostate,  410 
Hypospadias,  443 

treatment  of,  443 
Hysterectomy,  abdominal,  74?,  756 

supravaginal,  partial,  744 
total,  746 

vaginal,  754 
Hysterorrhaphy,  712 

Imperforate  anus,  347 
Implantation  of  ureters,  371 
Indian  method  of  rhinoplasty,  582 
Inflammation  of  bladder,  383 

of  bone,  89 

of  breast,  676 

of  veins,  25 
Information  obtained  from  patient,  18 
Internal  tensors  of  larynx,  paralysis   of, 

635 
Intestinal  anastomosis,  247 
obstruction,  237 
acute,  237 
chronic,  253 
diagnosis  of,  240 
from  intussusception,  237 
operative  treatment  of,  244 
surgical  treatment  of,  242 
Intestine    and  intestines,  carcinoma   of, 
234 
diseases  and  injuries  of,  233 
examination  of,  233 
palpation  of,  233 
percussion  of,  234 
resection  of,  252 

strangulation  of,  by  bands  or  divertic- 
ula, 253 
suturing  of  wounds  of,  251 
Intra-cranial  hemorrhage,  472 
Intussusception,  237 
Intussusceptum,  237 
Intussuscipiens,  237 
Invagination  of  bowel,  237 
Irrigation  of  joints,  114 
Irritable  ulcer,  338 


INDEX. 


791 


Ischio-rectal  abscess,  332 
Ischochymia,  226 

Jacksonian  epilepsy,  504 
Jaw  and  jaws,  ankylosis  of,  192 
Esmarch's  operation  for,  193 

carcinoma  of,  189 

closure  of,  193 

deformities  of,  186 

diseases  of,  186 

enchondroma  of,  189 

epithelioma  of,  189 

fibroma  of,  188 

lower  operations  on,  192 

necrosis  of,  187 

osteomata  of,  189 

periostitis  of,  187 

phosphorus-necrosis  of,  187 

sarcoma  of,  190 

tumors  of,  187 
Joints,  contusions  of,  in 

examination  of,  145 

loose  bodies  in,  142 

sprains  of,  in 

tuberculosis  of,  1 53 

wounds  and  injuries  of,  n2,  113 
Jury-mast,  540 

Kangaroo  tendon  for  deep  sutures,  266 
Keyes'  operation  for  varicocele,  455 
Kidney,  cysts  of,  366 

diseases  of,  347 

examination  of,  351 

floating,  352 

hydatid  cysts  of,  365,  749 

injuries  of,  349 

movable,  352 

sarcoma  of,  366 

surgical,  361 
anatomy  of,  347 

tuberculosis  of,  365 

tumors  of,  366 

wounds  of,  350 
Knee-joint  disease,  161 

housemaid's,  no 

tuberculosis  of,  161 
Kocher's  method  of  reducing  dislocations 
of  shoulder,  123 

operation  for  removal  of  entire  tongue, 
184 
Kraske's  operation  for  cancer  of  the  in- 
testine, 236 

Laparotomy  in  abdominal  wounds,  211 
Laryngectomy,  644 


Laryngitis,  608 

acute  infantile,  609 

catarrhal,  608 

chronic,  611 

chorditis  tuberosa,  614 

diphtheritic,  604 

sicca,  613 

subglottic,  chronic,  613 
Laryngoscope,  588 
Laryngoscopy,  588 
Larynx,  588 

abscess  of,  617 

burns  and  scalds  of,  601 

cancer  of,  629 

chondritis  and  perichondritis  of,  617 

contusions  of,  593 

diseases  of,  608 

dislocation  of  cartilages  of,  584 

edema  of,  614 

gunshot  wounds  of,  603 

incised  wounds,  603 

intubation  of,  642 

malformations  of,  638 

malignant  tumors  of,  629 

neuralgia  of,  631 

neuroses  of,  631 

paralysis  of,  631 

stenosis  of,  637 

strictures  of,  636 

syphilis  of,  623 

trachoma  of,  614 

tuberculosis  of,  619 

tumors  of  623 

ulcers  of,  619  ^ 

wounds  and  injuries  of,  600 
external,  602 
treatment  of,  604 
Lavage  of  stomach,  233 
Lawn-tennis  arm,  105 
Leg,  cerebral  center  for,  458 
Leiter's  cystoscope,  391 
Leonard's  trephine,  476 
Leptomeningitis,  490 
Ligature  for  internal  piles,  327 
Lilienthal's  bullet  probe,  484 
Lip,  cysts  of,  171 

epithelioma  of  173 

nevi  of,  171 
Lips,  affections  of,  166 

chapped,  172 

cracked,  172 

hypertrophy  of,  172 

inflammation  of,  172 

tumors  of,  171 

wounds  of,  172 


792 


INDEX. 


Litholapaxy,  394 

Lithotomy,  lateral,  393,  399,  400 

median,  393,  401 

perineal,  393,  400 

suprapubic,  393,  403 
Lithotritcs,  395 
Lithotrity,  395 

perineal,  402 
Littre's  hernia,  261 
Liver,  abscess  of,  292 

dermoid  cysts  of,  291 
diagnosis  of,  293 

diseases  and  injuries  of,  290 

examination  of,  291 

floating,  298 

hydatid  cysts  of,  296 

rupture  of,  291 

wounds  of,  291 
Loose  bodies  in  joints,  142 
Lordosis,  525 
Loreta's  operation,  230 
Lupus  of  nose,  567 

and  syphilis,  differential  diagnosis   of, 

567 
Luxatio  erecta,  527 

Macewen's  method  in  aneurysm,  40 
of  compressing  aorta,  29 

charts,  489 

operation  for  the  radical  cure  of  hernia, 
267 
Macroglossia,  180 
Macrostoma,  170 
Main  en  griffe,  554 
Massage  in  sprains,  113 
Mastitis,  676 

Mastoid  disease,  incision  of  cells  in,  494 
Maxillary  sinus,  599 
McBurney's  point,  275 
Meatus,  urinary,  stricture  of,  437 
Meckel's  ganghon,  removal  of,  546 
Meningitis,  486 

differential  diagnosis  of,  486 
Menorrhagia,  705 
Menstruation,  disorders  of,  704 
Meteorismus  peritonei,  281 
Metritis,  718 
Microstoma,  170 
Mind-blindness,  471 
Morbus  coxae,  153 

coxarius,  153 
Morton's  fluid,  223 
Mother's  mark,  27 
Motor  areas  of  brain,  456 
paralysis  of,  454 


Mouth,  diseases  and  injuries  of,  179 
Mucocele  in  frontal  sinus,  605 
Murphy's  button,  268 
Muscle,  contractures  of,  107 

diseases  and  injuries  of,  105 

obturator  internus,  133 

ossification  of,  107 

rupture  of,  105 

wounds  of,  106 
Myalgia,  106 
Myo-fibroma,  665 
Myositis,  106 

ossificans,  107 

suppurative,  106 
Myxomata,  665 

Neck,  abscess  of,  670 

cellulitis  of,  670 

contusions  of,  671 

cysts  of,  669 

diseases  and  injuries  of,  669 

malformations  of,  669 

tumors  of,  671 

wounds  of,  671 
Necrosis,  92 
Nelaton's  line,  138 
Nephrectomy,  354,  358 
Nephro-lithotomy,  357 
Nephrorrhaphy,  358 

Nerve  or   nerves,  contusions    and   com- 
pression of,  547 

cranial,  479 

extra-cranial  lesions  of,  550 
intra-cranial  lesions  of,  481 

facial,  diagnosis  of  lesions  of,  481,  550 

fifth,  diagnosis  of  lesions  of,  481 
methods  of  reaching,  546 

glosso-pharyngeal,  482 

great  sciatic,  diagnosis  of  lesions  of,  555 

inflammation  of,  543 

injuries  and  diseases  of,  543 

remote    effects   following,  treatment 

of.  549 
median,  diagnosis  of  lesions  of,  553 
musculo-spiral,  diagnosis  of  lesions  of, 

553 
olfactory,  diagnosis  of  lesions  of,  479 
optic,  diagnosis  of  lesions  of,  480 
pneumogastric,  diagnosis  of  lesions  of, 

482 
of  posterior  cervical  muscles,  division 

of,  for  wry  neck,  537 
radial,  diagnosis  of  lesions  of,  553 
recurrent  laryngeal,  diagnosis  of  lesions 

of,  553 


INDEX. 


793 


Nerve,  sixth,  diagnosis  of  lesions  of,  481 

special,  diagnosis  of  lesions  of,  550 

spinal  accessory,  482 

ulnar,  diagnosis  of  lesions  of,  553 

wounds  of,  547 

immediate  effects  of,  548 
remote  effects  of,  549 
treatment  of,  549 
Neuralgia,  544 

epileptiform,  546 

of  scars,  surgical  treatment  of,  546 

treatment  of,  546 
Neuritis,  543 

multiple,  544 
Neuroses  of  larynx,  631 

of  nasal  passages,  594 
Nevi  of  lips,  171 

of  tongue,  185 
Nevus,  27 
Nose,  abscess  of,  580 

accessory  sinuses  of,  diseases  and  in- 
juries of,  588 

adenomata  of,  563 

angeiomata  of,  563 

asymmetry  of,  576 

atrophic  catarrh  of,  575 

congenital  malformations  of,  58 1 

deformities  of,  580 

enchondromata  of,  563 

exostoses  and  osteomata  of,  563 

fibromata  of,  561 

foreign  bodies  in,  557 

hypertrophic  catarrh  of,  572 

injuries  of,  556 

malignant  growths  in,  563 

parasites  in,  558 

plugging  of,  565 

polypi  of,  559 

rhinoliths  in,  558 

septum  of,  diseases  and  displacements 
of,  577 

ulcers  of,  566 
Nose-bleed,  564 

Obstruction,  intestinal,  237 

acute,  237 

chronic,  253 

diagnosis  of,  231 

operative  treatment  of,  244 

surgical  treatment  of,  242 

treatment  of,  241 
Omentum,  sarcoma  of,  289 
Orchitis,  448 
syphilitic,  448 

differential  diagnosis  of,  448 


Orchitis,  tubercular,  449 

Osseous  system,  injuries  and  diseases  of, 

49 
Osteitis,  syphilitic,  95 

tubercular,  94 
Osteo-malacia,  97 
Osteo-myelitis,  91 
Osteo-periostitis,  90 
Ovarian  cyst,  760 
diagnosis  of,  762 

cystomata,  766 

dermoids,  762 

tumors,  759 
Ovaries,  anomalies  of,  698 

inflammation  of,  727 

removal  of,  765 
Ovariotomy,  765 
Ovaritis,  727 
Ovary,  cysts  of,  760 

dermoid  cysts  of,  762 

new  growths  in,  benign,  756 
malignant,  760 

tuberculosis  of,  734 

tumors  of,  762 
Ozena,  576 

Facet's  disease,  676 

Pain  in  injury  and  disease  of  abdomen, 

202 
Palate,  cleft,  174 

syphilis  of,  179 

tumors  of,  179 

ulceration  of,  179 
Palpation,  bimanual,  689 
Pancreas,  abscess  of,  315 

cancer  of,  316 

cysts  of,  315 

diseases  and  injuries  of,  314 
Pancreatic  hemorrhage,  315 
Papillomata,  666 

of  bladder,  404 

of  rectum,  340 
Paracentesis  pericardii,  23 

of  right  auricle,  22 

thoracis,  646 
Paralysis  from  injuries  to  brain,  471 

of  laryngeal  nerve,  631 
Paraphimosis,  445 
Parotid  gland,  diseases  of,  673 

tumors  of,  673 
Parotitis,  673 

Parturition,  injuries  due  to,  698 
Patella,  fracture  of,  82 

treatment  of,  82 
Patients,  examination  of,  19 


794 


INDEX. 


Patients,  position  of,  19 
Pelvic  abscess,  764 
cellulitis,  728 
hematocele,  453 
inflammations,  724,  729 
peritonitis,  728 
treatment  of,  730 
Penis,  amputation  of,  446 
diseases  and  injuries  of,  443 
epithelioma  of,  445 
and  urethra,  relative  sizes  of,  436 
Pericardium,  effusion  into,  23 
Perinephric  abscess,  360 
Perinephritic  abscess,  360 
Perineum,  injuries  of,  698 
repair  of,  699 
rupture  of,  698 
complete,  700 
incomplete,  700 
surgery  of,  698 
Periproctitis,  332 
Peritoneum,  281 
carcinoma  of,  288 
examination  of,  281 
injuries  and  diseases  of,  28 1 
rupture  of,  289 
tumors  of,  289 
Peritonitis,  282 
pelvic,  728 
plastic,  282 
septic,  283 
suppurative,  285 
tubercular,  286 
Perityphlitic  abscess,  274 
Petit's  triangle,  273 
Pharynx,  diseases  of,  195 

tumors  of,  196 
Phimosis,  427,  445 
treatment  of,  427 
Phonendoscope,  205,  234 
Piles.     (See  I-Jei>wrrhoids?) 
Pleural  cavity,  effusions  into,  645 
Pneumatocele,  464 
Polypus,  nasal,  559 
of  rectum,  339 
of  uterus,  746 
Pott's  disease  of  spine,  530 

differenual  diagnosis  of,  536 
treatment  of,  537 
Iracture,  86 
Pregnancy  coexisting  with  fibroids,  741 

extra-uterine,  766 
Probe,  Fliihrer's  aluminum,  483 
improvised,  485 
Lilienthal's,  484 


Probe,  telephonic,  of  Girdner,  483 
Proctitis,  330 
Prolapse  of  anus,  327 
of  rectum,  328 
of  uterus,  713 
Prostate  gland,  anatomy  of,  409 
atrophy  of,  411 
calculus  of,  413,  419 
carcinoma  of,  413,  419 
diseases  of,  409 
examination  of,  412 
hypertrophy  of,  410 
diagnosis  of,  413 
double  castration  for,  415 
symptoms  of,  41 1 
treatment  of,  413 
injuries  of,  409 
sarcoma  of,  419 
tuberculosis  of,  413 
wounds  of,  420 
Prostatectomy,  415 
Prostatic  disease,  410 
Prostatitis,  417 
acute,  417 
chronic,  417 
follicular,  acute,  417 

chronic,  417 
gouty,  418 

parenchymatous,  418 
tubercular,  419 
Pruritus  ani,  329 
Psammoma,  667 
Psoas  abscess,  534 
Ptosis,  481 
Puffy  tumor,  464 
Pyloroplasty,  230 
Pylorus,  cicatricial  stricture  of,  233 

digital  divulsion  of,  230 
Pyonephrosis,  364 
Pyosalpinx,  726,  764 

Rachitis,  96 
Ranula,  180 
Rectum,  cancer  of,  236 
diagnosis  of,  235 

condylomata  of,  341 

congenital  malformations  of,  345 

examination  of,  320 

foreign  bodies  in,  320 

inflammatory  diseases  of,  330 

injuries  and  diseases  of,  320 

manual  exploration  of,  321 

papillomata  of,  340 

polypus  of,  339 

prolapse  of,  328 


INDEX. 


795 


Rectum,  stricture  of,  341 

syphilitic  ulceration  of,  331 

tubercular  ulceration  of,  331 

tumors  of,  339 

warty  growths  of,  340 

wounds  of,  322 
Renal  calculus,  354 
Resection  of  ankle,  163 
Respiratory  tract,  diseases    and   injuries 

of.  556 
Retention  of  urine,  380 
Retro-pharyngeal  abscess,  195 
treatment  of,  196 

tumors,  196 
Rhinitis,  570 

purulent,  577 
Rhinoliths,  558 
Rhinoscleroma,  556 
Rhinoscopy,  584 

anterior,  585 

posterior,  585 
Rickets,  96 
Rings,  Abbe's,  248 
Rolando,  fissure  of,  460 

Chiene's  method  of  fixing,  460 
Rontgen  rays  in  surgery,  771 
Rupture  of  bladder,  378 

of  muscle,  105 

of  stomach,  217 

Sacro-iliac  joint  disease,  158 
tuberculosis  of,  1 58 
diagnosis  of,  160 
Salivary  calculi,  179 
Salpingitis,  724,  725 
Saphenous  vein,  internal,  varix  of,  26 
Sarcoma  and  sarcomata,  666 
of  bone,  loi 

diagnosis  of,  104,  665 
of  ovary,  760 
of  skull,  496 
of  uterus,  748 
diagnosis  of,  749 
Sayre's  dressing  for  fractured  clavicle,  61 

jacket,  539 
Scalp,  contusions  of,  463 
diseases  and  injuries  of,  462 
fatty  tumors  of,  463 
horns  of,  464 
sebaceous  tumors  of,  463 
tumors  of,  463 
warts  of,  464 
wounds  of,  462 
Scars,  neuralgia  of,  546 
Sciatica,  545 


Sciatica,  surgical  treatment  of  546 
Scirrhous  carcinoma  of  breast,  665 
Scrotum,  diseases  of,  447 
edema  of,  447 
elephantiasis  of,  447 
epithelioma  of,  447 
Senn's  decalcified  bone-plates,  247 
Septic  inflammation  of  bone,  91 

treatment  of,  92 
Septum,  nasal,  abscess  of,  580 
deviation  of,  577 
hematoma  of,  580 
perforating  ulcer  of,  580 
Sequestrotomy,  93 
Sequestrum,  93 

Shoulder,  cerebral  center  for,  558 
examination  of,  for  injury,  119 
Shoulder-joint  disease,  163 

tuberculosis  of,  163 
Silver-fork  deformity,  74 
Simple  ulcer  of  tongue,  183 
Sims'  position,  687 
Singer's  node,  614 
Skin,  examination  of,  20 
Skull,  injuries  of,  464 
Smith,  Nathan  R.,  anterior  splint  of,  81 
Sounding  for  urinary  calculus,  388 

indications  for,  388 
Specula,  691 
bivalve,  692 
cylindrical,  692 
examination  with,  691 
Sims',  692 
Speech,  Broca's  center  for.  459 
Spermatic  cord,  diseases  of.  453 
hydrocele  of,  diffused,  453 
encysted,  454 
Sphenoidal  sinus,  594 
Sphincter  ani,  spasm  of,  339 
Sphincterismus,  339 
Spina  bifida,  521 
Spinal  cord,  compression  of,  510 
concussion  of,  510 
hemorrhage  into,  510 
locahzation  of  injury  of,  514 
meningocele,  522 
meningo-myelocele,  522 
reflexes,  517 
wounds  of,  520 
Spine,  506 

abscess  of,  treatment  of,  540 
curvature  of,  anterior,  524 
lateral,  625 
posterior,  529 
curvatures  of,  treatment  of,  527 


796 


INDEX. 


Spine,  deformities  of,  521 
dislocations  of,  520 
examination  of,  507 
excurvation  of,  529 
extra-medullary,  hemorrhage  of,  510 
fractures  of,  512 

diagnosis  of  position  of,  513 
intra-meduUary,  hemorrhage  of,  510 
kyphosis  of,  529 
Pott's  disease  of,  530 
railway,  508 
sprains  of,  508 
surgical  anatomy  of,  506 

operations  on,  1 19 
tuberculosis  of,  530 
tumors  of,  525 
Spleen,  abscess  of,  319 
cysts  of,  320 

diagnosis  of,  320 
examination  of,  for  injury,  317 
rupture  of,  320 
tumors  of,  320 
wounds  of,  317,  319 
Splenectomy,  318 
Spondylitis,  530 
Sprains,  1 1 1 
Squint,  convergent,  481 
Stomach,  carcinoma  of,  220 
dilatation  of,  231 
diseases  and  injuries  of,  216 
examination  of,  215 
foreign  bodies  in,  217 
irrigation  of,  233 
lavage  of,  233 
mechanical  fixation  of,  218 
operations  on,  231 
rupture  of,  217 
ulcer  of,  218 
Stomach-contents,  examination  of,  222 
Stone  in  the  bladder,  386 
Strabismus  from  paralysis  of  third  nerve, 

481 
Strangulation   of    intestine  by  bands   or 

diverticula,  253 
Stricture  of  esophagus,  196,  229 
of  pylorus,  229 
of  rectum,  341 
of  ureter,  374 
of  urethra,  434 
Student's  elbow,  no 
Suppurative    inflammation    of    muscles, 
106 
teno-synovitis,  107 
Suprameatal  triangle,  494 
Supravaginal  hysterectomy,  744 


Surgical  kidney,  361 
Suture,  continuous,  213 

Czerny-Lembert,  212 

interrupted,  213 

Lembert,  212 
Sylvius,  fissure  of,  461 
Syme's  staff,  440 
Synovitis,  145 
Syphilides,  654 
Syphilis,  648 

hereditary,  660 

of  larynx,  622 

methods  of  transmission  of,  648 

mucous  patches  in,  654 

of  nasal  cavities,  568 

of  palate,  179 

primary  sore  of,  649 
stage  of,  649 

secondary  stage  of,  652 

treatment  of,  662 
Syphilitic  orchitis,  448 

differential  diagnosis  of,  656 

ulcers  of  palate,  179 
Syphiloderm,  653 

Talipes  valgus,  112 
Telangiectasis,  27 
Telephone  probe,  483 
Temperature,  value  of,  in  diagnosis,  21 
Teno-synovitis,  107 

chronic  tubercular,  108 
suppurative,  108 
Tenotomy,  107 

Testicle  and  testicles,  carcinoma  of,  449 
differential  diagnosis  of,  449 

cystic,  451 

hydrated,  450 

inflammation  of,  448 

malignant,  disease  of,  449 

retained,  451 

sarcoma  of,  449 

syphilis  of,  448 

tuberculosis  of,  449 

tumors  of,  benign,  451 
Thecitis,  107 

Thermesthesiometer,  548 
Thomas's  splint,  157 
Thoracoplasty,  647 
Thoracotomy,  647 
Thrombosis,  25 

of  lateral  sinus,  492 
Thyroid  body,  674 
Tobold's  laryngoscope,  588 
Tongue,  atrophy  of,  180 
cancer  of,  182 


INDEX. 


797 


Tongue,  chancre  of,  182 

epithelioma  of,  182 

hypertrophy  of,  180 

inflammation  of,  181 

injuries  of,  i8i 

malformations  of,  180 

nevi  of,  185 

removal  of,  entire,  184 
partial,  183 

syphilis  of,  181 

tuberculosis  of,  181 

tumors  of,  185 

ulcer  of,  181 

wounds  of,  181 
Tongue-tie,  181 

Tonsil  and  tonsils,  calcareous  concretions 
of,  194 
carcinoma  of,  195 
caseous  concretions  of,  194 
hypertrophy  of,  194 
sarcoma  of,  195 
tumors,  malignant,  of,  195 
Tonsillitis,  193 
Tourniquet,  Esmarch's,  28 
Trachea,  burns  and  scalds  of,  639 

malformations  of,  638 

tumors  of,  639 
Tracheocele,  639 
Tracheotomy,  640 
Trachoma  of  larynx,  614 
Traumatic  aneurysm,  30 

dislocations,  114 
Trendelenburg's  position,  688 
Trephining,  operation  of,  475 
Tubal  pregnancy,  766 
diagnosis  of,  766 
Tuberculosis  of  ankle-joint,  162 

of  brain,  496 

of  elbow-joint,  163 

of  female  genital  tract,  733 

of  hip-joint,  153 

of  joints,  152 

of  knee-joint,  161 

of  sacro  iliac-joint,  158 

of  shoulder-joint,  163 

of  spine,  530 

of  wrist-joint,  164 
Tubes,  new  growths  in,  759 
Tufnell's  method  in  aneurysm,  39 
Tumors,  663 

of  bladder,  404 

of  bone,  98 

of  brain,  497,  500 

differential  diagnosis  of,  497 
general  symptoms  of,  497 


Tumors  of  brain,  prognosis  of,  503 
treatment  of,  503 
cartilaginous,  99,  665 
of  cerebellum,  503 
classification  of,  663 
of  connective  tissue,  663 
epithelial,  666 
fatty,  463 
intestinal,  234 
of  jaws,  187 
of  kidney,  366 
of  lips,  171 

malignant,  of  bone,  loi 
of  neck,  673 
of  nose,  external,  556 
ovarian,  762 
of  ovary,  diagnosis  of,  762 

treatment  of,  765 
of  parotid,  673 
of  rectum,  339 
retro-pharyngeal,  196 
of  scalp,  463 
of  tongue,  185 

Ulcer  of  nose,  566 

siinple,  of  tongue,  183 

of  stomach,  218 

syphilitic,  of  tongue,  183 

tubercular,  of  tongue,  183 

varicose,  26 
Ureter,  rupture  of,  369 

stricture  of,  374 
Ureteral  calculus,  373 
Ureterotomy,  371 
Ureters,  diseases  of,  368 

examination  of,  in  female,  694 

inflammation  of,  373 

injuries  of,  368 

methods  of  catheterizing,  694 

surgical  anatomy  of,  368 
Urethra,  calculus  lodged  in,  423 

diseases  and  injuries  of,  420 

foreign  bodies  in,  423 

and  penis,  relative  sizes  of,  435 

rupture  of,  421 

stricture  of,  434 
annular,  435 
behind  bulbo-membranous  junction, 

438 
deep  impassable,  439 

permeable  only  to  filiform  bougies, 

437 
inflammatory,  434 
of  large  caliber,  437 
hnear,  435 


798 


INDEX. 


Urethra,  stricture  of  pendulous  portion,  437 
of  meatus  and  fossa  navicularis,  437 
spasmodic,  434 
tortuous,  435 

Urethral  fistula,  439 
injections  in  early  stage  of  gonorrhea, 

432 
Urethritis,  425 

gonorrheal,  425 

simple,  425 
Urethrotomy,  external,  440 

internal,  438 

without  guide,  441 
Urinary  calculus,  386 

pouches,  442 
Urine,  extravasation  of,  439 

retention  of,  380 
Uterine  polypi,  747 

sound,  693 
Uterus,  anomalies  of,  697 

anteflexion  of,  708 

artificial  dilatation  of,  693 
gradual,  693 

carcinoma  of,  639,  753 

displacement  of,  708,  739 

examination  of,  and  bladder,  694 

fibro-myomata  of,  738 

inflammations  of,  717,  723 

inversion  of,  714 

myomata  of,  738 

polypoid  growths  in,  738 
interstitial,  739 
submucous,  739 
subperitoneal,  739 

prolapse  of,  713 

reposition  of,  709 

retroflexion  of,  709 

retroversion  of,  709 

sarcoma  of,  768 

tumors  of,  738 
fibroid,  741 

Vagina,  injuries  of,  698 
Vaginal  examination,  688 
Vaginitis,  716 
Varicocele,  454 
Varicose  veins,  25 
Varix,  25 

aneurysmal,  48 

arterial,  48 

of  internal  saphenous  vein,  25 
Vascular  system,  examination  of,  22 


Veins,  diseases  of,  24 

varicose,  25 

wounds  of,  24 
Velpeau's  bandage,  61 

dressing  for  dislocation,  121 
for  fracture  of  clavicle,  61 
Ventricles,  over-distention  of,  22 
Villous  tumors  of  bladder,  405 
Volvulus,  253 
Vulva,  inflammation  of,  915 

injuries  of,  698 

Wardrop's  operation  for  aneurysms, 

35 
Warts  on  scalp,  464 
Wens,  463 

Wharton's  duct,  calculi  in,  179 
Wheelhouse's  method  of  perinealsection, 

441 
Whitehead's   operation    for   excision   of 
piles,  327 
for  removal  of  entire  tongue,  185 
Witzel's  method  of  performing   gastros- 
tomy, 199 
Word-blindness,  471 
Word-deafness,  491 
Wounds  of  abdomen,  208 
after-treatment  of.  214 
arrest  of  hemorrhage  in,  212 
enterectomy  in,  213 
incision  in,  212 
non-penetrating,  208 
omental  grafting  in,  214 
penetrating,  209 
diagnosis  of,  209 
preparation  of  patient  for  operation 

in,  212 
search  for  perforation  in,  212 
symptoms  of,  209 
treatment  after  operation,  214 
of  back,  51 1 

gunshot,  probing  of,  in  head,  483  . 
of  intestine,  suturing  of,  212 
of  muscle,  106 
of  skull,  482 
of  tongue,  181 
Wry  neck,  537 

X-  or  Rontgen  rays,  771 

Zinc-glue  bandages  for  varicose  veins, 
26 


CATALOGUE 

OF   THE 

MEDICAL  PUBLICATIONS 

OF 

W.  B.  SAUNDERS, 

No,   925   WALNUT   STREET,   PHILADELPHIA. 


Arranged  Alphabetically  and  Classified  under  Subjects. 


*  I  ^riE  books  advertised  in  this  Catalogue  as  being  sold  by  subscription  are  usually  to  be 
obtained  from  traveling  solicitors,  b«t  they  will  be  sent  direct  from  the  office  of  pub- 
lication (charges  of  shipment  prepaid)  upon  receipt  of  the  prices  given.  AU  the  other 
books  advertised  are  commonly  for  sale  by  booksellers  in  all  parts  of  the  United  States  j 
but  any  book  will  be  sent  by  the  publisher  to  any  address,  carriage  prepaid,  on  receipt  o£ 
the  published  price. 

Money  may  be  sent  at  the  risk  of  the  publisher  in  either  of  the  following  ways  r 
A  post-office  money  order,  an  express  money  order,  a  bank  check,  and  in  a  registered 
ktter.     Money  sent  in  any  other  way  is  at  the  risk  of  the  sender. 

See  pages  30,  31,  for  a  List  of  Contents  classified  according  to  subjects. 


LATEST  PUBLICATIONS. 


Amer. Text-Book  of  Genito-Urinary  and  Skin  Diseases.  Page  4. 

Macdonald^s  Surgical  Diagnosis,  just  Ready.   See  page  16. 

Anders'  Practice  of  Medicine — Revised  Edition.   See  page  6. 

Moore's  Orthopedic  Surgery,  just  Ready.   See  page  17. 

Penrose's  Diseases  of  Women.   See  page  18. 

Mallory  and  Wright's  Pathological  Technique.   See  page  16. 

Van  Valzah  and  Nisbet's  Diseases  of  the  Stomach.   See  page  28. 

American  Year-Book  of  Medicine  and  Surgery.   See  page  6. 

Senn's  Genito-Urinary  Tuberculosis.  See  page  25. 

Sutton  and  Giles'  Diseases  of  Women.   See  page  28. 

Stoney's  Nursing — Revised  Edition.   See  page  27. 

Garrigues'  Diseases  of  Women — Revised  Edition.   See  page  ii. 

Keen's  Surgical  Complications  of  Typhoid  Fever.   See  page  I5. 

Gould  and  Pyle's  Curiosities  of  Medicine.   See  page  n. 

De  Schweinitz'  Diseases  of  the  Eye — Revised  Edition.   Page  lo. 

Chapin's  Compendium  of  Insanity,  just  Ready.   See  page  8. 

Church  and  Peterson's  Nervous  and  Mental  Diseases.   Page  9. 

Saunders'  Medical  Hand-Atlases.   See  page  2. 

DaCosta's  Surgery — Revised  and  Enlarged  Edition.    See  page  lo. 


SPECIAL  ANNOUNCEMENT. 


Mr.  Saunders  is  pleased  to  announce  that  arrangements  have  been  completed  for  the 
publication  of  an  English  edition  of  the  world-famous 

Lehmann  medicinische  Handatlanten. 

For  scientific  accuracy,  pictorial  beauty,  compactness,  and  cheapness  these  books 
surpass  any  similar  volumes  ever  published.      Each  volume  contains  from 

50  to  100  Colored  Plates, 

besides  numerous  other  illustrations  in  the  text.  These  colored  plates  have  been  executed 
by  the  most  skilful  German  lithographers,  in  some  cases  twenty  or  more  impressions  being 
required  to  obtain  the  desired  result.  There  is  a  full  and  appropriate  description  of  each 
plate  (printed,  for  convenience,  opposite  the  plate),  together  with  a  condensed  outline  of 
the  subject  to  which  the  book  is  devoted. 

The  same  careful  and  competent  editorial  supervision  will  be  secured  in  the 
English  edition  as  in  the  originals.  The  translations  will  be  directed  and  edited  by  the 
leading  American  specialists  in  the  different  sul^jects. 

The  great  advantage  of  natural  pictorial  representation  is  indisputable.  For  lasting  and 
practical  knowledge,  one  accurate  illustration  is  better  than  several  pages  of  dry 
description. 

These  Atlases  offer  a  ready  and  satisfactory  substitute  for  clinical  observation,  avail- 
able only  to  the  residents  of  large  medical  centers  ;  and  with  such  persons  the  requisite 
variety  is  seen  only  after  long  years  of  routine  hospital  service. 

By  reason  of  their  projected  universal  translation  and  reproduction,  affording  inter- 
national distribution,  the  publishers  have  been  enabled  to  secure  for  these  Atlases  the  best 
artistic  and  professional  talent,  to  produce  them  in  the  most  elegant  style,  and  yet  to 
cflfer  them  at  a  price  heretofore  unapproached  in  cheapness.  The  success  of  the  under- 
taking is  demonstrated  by  the  fact  that  volumes  have  already  appeared  in  German,  English, 
French,  Italian,  Russian,  Spanish,  Danish,  Swedish,  and  Hungarian. 

While  appreciating  the  value  of  such  colored  plates,  the  profession  has  heretofore  been 
practically  debarred  from  purchasing  similar  works  because  of  their  extremely  high  price, 
made  necessary  by  the  limited  sale  and  the  enormous  expense  of  production.  The  very 
low  price  of  these  Atlases  will  place  them  within  the  reach  of  even  the  novice  in  practice. 

NOW  READY. 

Atlas  of  Internal  Medicine  and  Clinical  Diagnosis.  By  Dr.  Chr.  Jakob,  of  Erlangen.  Edited 
by  Augustus  A.  Eshner,  M.D.,  Professor  of  Clinical  Medicine  in  the  Philadelphia  Polyclinic;  At- 
tending Physician  to  the  Philadelphia  Hospital.  68  colored  plates,  and  64  illustrations  in  the  text. 
Cloth,  S3. 00  net. 

Atlas  of  Legal  IMedicine.  By  Dr.  E.  R.  von  Hofmann,  of  Vienna.  Edited  by  Frederick  Peter- 
son, M.D.,  Clinical  Professor  of  Mental  Diseases,  Woman's  Medical  College,  New  York;  Chief 
of  Clinic,  Nervous  Dept.,  College  of  Physicians  and  Surgeons,  New  York.  With  120  colored  fig- 
ures on  56  plates,  and  193  beautiful  half-tone  illustrations.     Cloth,  J3.50  net. 

Atlas  of  Diseases  of  the  Larynx.  By  Dr.  L.  Grunwald,  of  Munich.  Edited  by  Charles  P. 
Grayson,  M.D.,  Lecturer  on  Laryngology  and  Rhinology  in  the  University  of  Pennsylvania; 
Physiclan-in-Charge,  Throat  and  Nose  Department,  Hospital  of  the  University  of  Pennsylvania. 
With  10/  colored  figures  on  44  plates,  and  25  text-illustrations.     Cloth,  I2.50  net. 

Atlas  of  Operativ  Surgery.  By  Dr.  O.  Zuckf.rkandl,  of  Vienna.  Edited  by  J.  Chalmers 
DaCosta,  M.D.,  Clinical  Professor  of  Surgery,  Jelilerson  Medical  College,  Philadelphia  ;  Surgeon 
to  the  Philadelphia  Hospital.     With  24  colored  plates,  and  217  text  illustrations.     Cloth,  I3.00  net. 

Atlas  of  Syphilis  and  the  Venereal  Diseases.  By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited 
by  L.  Bolton  Bangs,  M.D.,  late  Professor  of  Genito-Urinary  and  Venereal  Diseases,  New  York 
Post-Graduate  Medical  School  and  Hospital.  With  71  colored  plates  from  original  water-colors, 
and  16  black-and-white  illustrations.     Cloth,  ^3.50  net. 

IN  PREPARATION. 

Atlas  of  External  Diseases  of  the  Eye.  By  Dr.  O.  Haab,  of  Zurich.  Edited  by  G.  E. 
DE  ScHWEiNiTZ,  M.D.,  Professor  of  Ophthalmology,  Jefl!"erson  Medical  College,  Philadelphia. 
With  100  colored  illustrations. 

Atlas  of  Skin  Diseases.  By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  With  80  colored  plates  from 
original  water-colors. 

Atlas  of  Pathological  Histology.  Atlas  of  Operative  Gynecology. 

Atlas  of  Orthopedic  Surgery.  Atlas  of  Psychiatry. 

Atlas  of  General  Surgery,  Atlas  of  Diseases  of  the  Ear. 


THE  AMERICAN   TEXT-BOOK  SERIES. 

AN  AMERICAN  TEXT=BOOK  OF  APPLIED  THERAPEUTICS. 

By  43  Distinguished  Practitioners  and  Teachers.  Edited  by  James  C. 
Wilson,  M.D.,  Professor  of  the  Practice  of  Medicine  and  of  Clinical 
Medicine  in  the  Jefferson  Medical  College,  Philadelphia.  One  hand- 
some imperial  octavo  volume  of  1326  pages.  Illustrated.  Cloth, 
$7.00  net;  Sheep  or  Half  Morocco,  $8.00  net.     Soid  by  Subscription. 

"  As  a  work  either  for  study  or  reference  it  will  be  of  great  value  to  the  practitioner,  as 
it  is  virtually  an  exposition  of  such  clinical  therapeutics  as  experience  has  taught  to  be  oi 
the  most  value.  Taking  it  all  in  all,  no  recent  publication  on  therapeutics  can  be  compared 
with  this  one  in  practical  value  to  the  working  physician." — Chicago  Clinical  Review. 

"■  The  whole  field  of  medicine  has  been  well  covered.  The  work  is  thoroughly  prac- 
tical, and  while  it  is  intended  for  practitioners  and  students,  it  is  a  better  book  for  the  general 
practitioner  than  for  the  student.  The  young  practitioner  especially  will  find  it  extremely 
suggestive  and  helpful." — The  Indian  Lancet. 

AN  AMERICAN  TEXT=BOOK  OF  THE  DISEASES  OF  CHILDREN. 

By  61  Eminent  Contributors.  Edited  by  Louis  Starr,  M.D.  ,  Physi- 
cian to  the  Children's  Hospital,  Philadelphia,  etc.;  assisted  by 
Thompson  S.  Westcott,  M.D.,  Attending  Physician  to  the  Dispen- 
sary for  Diseases  of  Children,  Hospital  of  the  University  of  Pennsyl- 
vania. In  one  handsome  imperial  octavo  volume  of  1190  pages, 
profusely  illustrated.  Cloth,  $7.00  net;  Sheep  or  Half  Morocco, 
^8.00  net.     Sold  by  Subscription. 

"This  is  far  and  away  the  best  text-book  on  children's  diseases  ever  published  in  the 
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We  congratulate  the  editor  upon  the  result  of  his  work,  and  heartily  commend  it  to  the 
attention  of  ever)'  student  and  practitioner. ' ' — Americati  Journal  of  the  Medical  Sciences. 

AN  AMERICAN  TEXT=BOOK  OF  DISEASES  OF  THE  EYE,  EAR, 
NOSE,  AND  THROAT. 

By  58  Prominent  Specialists.  Edited  by  G.  E.  de  Schweinitz,  M.D., 
Professor  of  Ophthalmology  in  the  Jefferson  Medical  College,  Phila- 
delphia ;  and  B.  Alexander  Randall,  M.D.,  Professor  of  Diseases 
of  the  Ear  in  the  University  of  Pennsylvania  and  in  the  Philadelphia 
Polyclinic.     Ready  soon. 


Illustrated  Catalogue  of  the  ** American  Text-Books"  sent  free  upon  application* 


4  Medical  Publications  of  W.  B.  Saunders. 

AN  AMERICAN   TEXT-BOOK    OF   GENITO=URINARY  AND  SKIN 
DISEASES. 

By  47  Eminent  Specialists  and  Teachers.  Edited  by  L.  Bolton 
Ban(;s,  M.D.,  Late  Professor  of  Genito-Urinary  and  Venereal  Diseases, 
New  York  Post-Graduate  Medical  School  and  Hospital ;  and  W. 
A.  Hardaway,  M.D.,  Professor  of  Diseases  of  the  Skin,  Missouri 
Medical  College.     Cloth,  $7.00  net;  Sheep  or  Half  Morocco,  $8.00  net. 

This  latest  addition  to  the  series  of  "  American  Text-Books  "  it  is  confidently  believed  will  meet 
the  requirements  of  both  students  and  practitioners,  giving,  as  it  does,  a  comprehensive  and  detailed 
presentation  of  tile  Diseases  of  the  Genito-Urinary  Organs,  of  the  Venereal  Diseases,  and  of  the 
Affections  of  the  Skin. 

Having  secured  the  collaboration  of  well-known  authorities  in  the  branches  represented  in  the 
undertaking,  the  Editors  have  not  restricted  the  Contributors  in  regard  to  the  particular  views  set 
forth,  but  have  offered  every  facility  lor  the  free  expression  of  their  individual  opinions.  The  work 
will  therefore  be  found  to  be  original,  yet  homogeneous  and  fully  representative  of  the  several  depart- 
ments of  medical  science  with  which  it  is  concerned. 

AN  AMERICAN  TEXT=BOOK  OF  GYNECOLOGY,  MEDICAL  AND 
SURGICAL. 

By  10  of  the  Leading  Gynecologists  of  America.     Edited  by  J.   M. 
Baldy,  M.D.,  Professor  of  Gynecology  in  the  Philadelphia  Polyclinic, 
etc.     Handsome  imperial  octavo  volume  of  over  700  pages,  with  360 
illustrations  in  the  text,  and  37  colored  and  half-tone  plates.      Cloth, 
$6.00  net;  Sheep  or  Half  Morocco,  $7.00  net.     Sold  by  Sicbscription. 
"  It  is  practical  from  beginnimg  to  end.     Its  descriptions  of  conditions,  its  recommen- 
dations  for  treatment,  and   above  all  the   necessary  technique  of  different  operations,  are 
clearly  and  admirably  presented.      .      .     .     It  is  well  up  to  the  most  advanced  views  of  the 
day,  and  embodies  all  the  essential  points  of  advanced  American  gynecology.     It  is  destined 
to  make  and  hold  a  place   in  gynecological    literature  which  will   be  peculiarly  its  own." — 
Medical  Record,  New  York. 

AN  AMERICAN  TEXT=BOOK  OF  LEGAL  MEDICINE  AND  TOXI- 
COLOGY. 

Edited  by  Frederick  Peterson,  M.D.,  Clinical  Professor  of  Mental 
Diseases  in  the  Woman's  Medical  College,  New  York;  Chief  of  Clinic, 
Nervous  Department,  College  of  Physicians  and  Surgeons,  New  York ; 
and  Walter  S.  Haines,  M.D.,  Professor  of  Chemistry,  Pharmacy, 
and  Toxicology  in  Rush  Medical  College,  Chicago.     In  Preparation. 

AN  AMERICAN  TEXT=BOOK  OF  OBSTETRICS. 

By  15  Eminent  American  Obstetricians.  Edited  by  Richard  C.  Nor- 
Ris,  M.D.;  Art  Editor,  Robert  L.  Dickinson,  M.D.  One  handsome 
imperial  octavo  volume  of  over  1000  pages,  with  nearly  900  beautiful 
colored  and  half-tone  illustrations.  Cloth,  $7.00  net;  Sheep  or  Half 
Morocco,  $8.00  net.     Sold  by  Siibscriptioti. 

"  Permit  me  to  say  that  your  American  Text-Book  of  Obstetrics  is  the  most  magnificent 
medical  work  that  I  have  ever  seen.  I  congratulate  you  and  thank  you  for  this  superb  work, 
which  alone  is  sufficient  to  place  you  first  in  the  ranks  of  medical  publishers." — Alexander 
J.  C.  Skene,  Professor  of  Gynecology  in  the  Long  Island  College  Hospital,  Brooklyn,  N.  V. 

"  This  is  the  most  sumptuously  illustrated  work  on  midwifery  that  has  yet  appeared.  In 
the  number,  the  excellence,  and  the  beauty  of  production  of  the  illustrations  it  far  surpasses 
every  other  book  upon  the  subject.  This  feature  alone  makes  it  a  work  which  no  medical 
library  should  omit  to  purchase." — British  Medical  Journal. 

"  As  an  authority,  as  a  book  of  reference,  as  a  '  working  book  '  for  the  student  or  prac- 
titioner, we  commend  it  because  we  believe  there  is  no  better." — A7nerica7i  Journal  of  the 
Medical  Sciences. 

Illustrated  Catalogue  of  the  ^'American  Text-Books  "  sent  free  upon  application. 


Medical  Publications  of  W.  B,  Saunders.  5 

AN  AMERICAN  TEXT=BOOK  OF  PATHOLOGY. 

Edited  by  John  Guiteras,  M.D.,  Professor  of  General  Pathology  and 
of  Morbid  Anatomy  in  the  University  of  Pennsylvania ;  and  David 
RiESMAN,  M.D.,  Demonstrator  of  Pathological  Histology  in  the 
University  of  Pennsylvania.     In  Prepai-ation. 

AN  AMERICAN  TEXT=BOOK  OF  PHYSIOLOGY. 

By  I o  of  the  Leading  Physiologists  of  America.  Edited  by  William 
H.  Howell,  Ph.D.,  M.D.,  Professor  of  Physiology  in  the  Johns  Hop- 
kins University,  Baltimore,  Md.  One  handsome  imperial  octavo 
volume  of  1052  pages.  Illustrated.  Cloth,  $6.00  net ;  Sheep  or  Half 
Morocco,  $7.00  net.     Sold  by  Subscription. 

"  We  can  commend  it  most  heartily,  not  only  to  all  students  of  physiology,  but  to  every 
physician  and  pathologist,  as  a  valuable  and  comprehensive  work  of  reference,  written  by 
men  who  are  of  eminent  authority  in  their  own  special  subjects." — London  Lancet. 

"  To  the  practitioner  of  medicine  and  to  the  advanced  student  this  volume  constitutes, 
we  believe,  the  best  exposition  of  the  present  status  of  the  science  of  physiology  in  the 
English  language." — American  Journal  of  tlie  A/edical  Sciences. 

AN  AMERICAN  TEXT=BOOK  OF  SURGERY.     Second  Edition. 

By  13  Eminent  Professors  of  Surgery.  Edited  by  William  W.  Keen, 
M.D.,  LL.D.,  and  J.  William  White,  M.D.,  Ph.D.  Handsome 
imperial  octavo  volume  of  1250  pages,  with  500  wood-cuts  in  the  text, 
and  39  colored  and  half-tone  plates.  Thoroughly  revised  and  enlarged, 
with  a  section  devoted  to  "  The  Use  of  the  Rontgen  Rays  in  Surgery." 
Cloth,  $7.00  net;  Sheep  or  Half  Morocco,  $8.00  net.  Sold  by  Sub- 
scription. 

"  Personally,  I  should  not  mind  it  being  called  THE  Text-Book  (instead  of  A  Text- 
Book),  for  I  know  of  no  single  volume  which  contains  so  readable  and  complete  an  account 
of  the  science  and  art  of  Surgery  as  this  does." — EDMUND  Owen,  F.R.C.S.,  Member  of 
the  Board  of  Examitiers  of  the  Royal  College  of  Stirgeotis,  England. 

"  If  this  text-book  is  a  fair  reflex  of  the  present  position  of  American  surgery,  we  must 
admit  it  is  of  a  very  high  order  of  merit,  and  that  English  surgeons  will  have  to  look  very 
carefully  to  their  laurels  if  they  are  to  preserve  a  position  in  the  van  of  surgical  practice." — 
London  Lancet. 

AN  AMERICAN  TEXT=BOOK  OF  THE  THEORY  AND  PRACTICE 
OF  MEDICINE. 

By  12  Distinguished  American  Practitioners.  Edited  by  William 
Pepper,  M.D.,  LL.D.,  Professor  of  the  Theory  and  Practice  of  Medi- 
cine and  of  Clinical  Medicine  in  the  University  of  Pennsylvania.  Two 
handsome  imperial  octavo  volumes  of  about  1000  pages  each.  Illus- 
trated. Prices  per  volume  :  Cloth,  $5.00  net ;  Sheep  or  Half  Morocco, 
g6.oo  net.      Sold  by  Subscription. 

"  I  am  quite  sure  it  will  commend  itself  both  to  practitioners  and  students  of  medicine, 
and  become  one  of  our  most  popular  text-books." — Alfred  Loomis,  M.D.,  LL.D.,  Pro- 
fessor of  Pathology  and  Pt-actice  of  Medicine,  University  of  the  City  of  New  York. 

"  We  reviewed  the  first  volume  of  this  work,  and  said  :  '  It  is  undoubtedly  one  of  the 
best  text-books  on  the  practice  of  medicine  which  we  possess.'  A  consideration  of  the 
second  and  last  volume  leads  us  to  modify  that  verdict  and  to  say  that  the  completed  work 
is  in  our  opinion  the  best  o{  its  kind  it  has  ever  been  our  fortune  to  see." — A^ew  York  Medical 
Journal. 

Illtfstrated  Catalogue  of  the  "American  Text-Books'*  sent  free  upon  application. 


6  Medical  Publications  of  W.  B.  Saunders. 

AN  AMERICAN  YEAR-BOOK  OF  MEDICINE  AND  SURGERY. 

A  Yearly  Digest  of  Scientific  Progress  and  Autlioritative  Opinion  in  all 
branches  of  Medicine  and  Surgery,  drawn  from  journals,  monographs, 
and  text-books  of  the  leading  American  and  Foreign  authors  and 
investigators.  Collected. and  arranged,  with  critical  editorial  com- 
ments, by  eminent  American  specialists  and  teachers,  under  the  general 
editorial  charge  of  Georcie  M.  Gould,  M.D.  One  handsome  imperial 
octavo  volume  of  about  1200  pages.  Uniform  in  style,  size,  and 
general  make-up  with  the  "American  Text-Book"  Series.  Cloth, 
$6.50  net ;  Half  Morocco,  ^7.50  net.     So/t/  by  Subscription. 

"  It  is  difficult  to  know  wliich  to  admire  most — the  research  and  industry  of  the  distin- 
guished band  of  experts  whom  Dr.  Gould  has  enlisted  in  the  service  of  the  Year-Book,  or  the 
wealth  and  abundance  of  the  contributions  to  every  department  of  science  that  have  been 
deemed  worthy  of  analysis.  .  .  .  It  is  much  more  than  a  mere  compilation  of  abstracts, 
for,  as  each  section  is  entrusted  to  experienced  and  able  contributors,  the  reader  has  the 
advantage  of  certain  critical  commentaries  and  expositions  .  .  .  proceeding  from  writers 
fully  qualified  to  perform  these  tasks.  .  .  .  It  is  emphatically  a  book  which  should  find 
a  place  in  every  medical  library,  and  is  in  several  respects  more  useful  than  the  famous 
'Jahrbiicher'  of  Gemiany." — London  Lancet. 

ANDERS'  PRACTICE  OF  MEDICINE.    Second  Edition. 

A  Text-Book  of  the  Practice  of  Medicine.  By  James  M.  Anders, 
M.D.,  Ph.D.,  LL.D.,  Professor  of  the  Practice  of  Medicine  and  of 
Clinical  Medicine,  Medico-Chirurgical  College,  Philadelphia.  In  one 
handsome  octavo  volume  of  1287  pages,  fully  illustrated.  Cloth, 
$^.^0  net;  Sheep  or  Half  Morocco,  $6.50  net. 

"  It  is  an  excellent  book, — concise,  comprehensive,  thorough,  and  up  to  date.  It  is  a 
credit  to  you  ;  but,  more  than  that,  it  is  a  credit  to  the  profession  of  Philadelphia — to  us." 
James  C.  Wilson,  Professor  of  the  Practice  of  Medicine  and  Clinical  Medicine,  Jefferson 
Medical  College,  Philadelphia. 

"  I  consider  Dr.  Anders'  book  not  only  the  best  late  work  on  Medical  Practice,  but  by 
far  the  best  that  has  ever  been  published.  It  is  concise,  systematic,  thorough,  and  fully  up 
to  date  in  everything.  I  consider  it  a  great  credit  to  both  the  author  and  the  publisher." — 
A.  C.  COWPERTHWAITE,  President  of  ihe  Illinois  Homeopathic  Medical  Association. 

ASHTON'S  obstetrics.     Fourth  Edition,  Revised. 

Essentials  of  Obstetrics.  By  W.  Easterly  Ashton,  M.D.,  Pro- 
fessor of  Gynecology  in  the  Medico-Chirurgical  College,  Philadelphia. 
Crowm  octavo,  252  pages;  75  illustrations.  Cloth,  $1.00;  interleaved 
for  notes,  $1.25. 

[See  Saunders^  Quesiioti-Conipends,  page  21.] 

<'  Embodies  the  whole  subject  in  a  nut-shell.  We  cordially  recommend  it  to  our  read- 
ers."— Chicago  Medical  Times. 

BALL'S  BACTERIOLOGY.     Third  Edition,  Revised. 

Essentials  of  Bacteriology  ;  a  Concise  and  Systematic  Introduction 
to  the  Study  of  Micro-organisms.  By  M.  V.  Ball,  M.D.,  Bacteriol- 
ogist to  St.  Agnes'  Hospital,  Philadelphia,  etc.  Crown  octavo,  218 
pages;  82  illustrations,  some  in  colors,  and  5  plates.  Cloth,  ^i.oo; 
interleaved  for  notes,  $1.25. 

[See  Saunders'  Question- Compends,  page  21.] 

"  The  student  or  practitioner  can  readily  obtain  a  knowledge  of  the  subject  from  a  perusal 
of  this  book.     The  illustrations  are  clear  and  satisfactory." — Medical  Record,  New  York. 


Medical  Publications  of  W.  B.  Saunders.  7 

BASTIN'S  BOTANY. 

Laboratory  Exercises  in  Botany.  By  Edson  S.  Bastin,  M.A., 
late  Professor  of  Materia  Medica  and  Botany,  Philadelphia  College  of 
Pharmacy.    Octavo  volume  of  536  pages,  with  87  plates.    Cloth,  $2.50. 

"It  is  unquestionably  the  best  text-book  on  the  subject  that  has  yet  appeared.  The 
work  is  eminently  a  practical  one.  We  regard  the  issuance  of  this  book  as  an  important 
event  in  the  history  of  pharmaceutical  teaching  in  this  country,  and  predict  for  it  an  unquali- 
fied success." — Alutiini  Report  to  the  Philadelphia  College  of  Phartnacy. 

"There  is  no  work  like  it  in  the  pharmaceutical  or  botanical  literature  of  this  country, 
and  we  predict  for  it  a  wide  circulation." — American  Journal  of  Pharmacy. 

BECK'S  SURGICAL  ASEPSIS. 

A  Manual  of  Surgical  Asepsis.  By  Carl  Beck,  M.D.,  Surgeon  to 
St.  Mark's  Hospital  and  the  New  York  German  Poliklinik,  etc.  306 
pages;  65  text-illustrations,  and  12  full-page  plates.     Cloth,  $1.25  net. 

"  An  excellent  exposition  of  the  '  very  latest '  in  the  treatment  of  wounds  as  practised 
by  leading  German  and  American  surgeons." — Birmingha7n  (Eng.)  Medical  Review. 

"This  little  volume  can  be  recommended  to  any  who  are  desirous  of  learning  the  details 
of  asepsis  in  surgery,  for  it  will  serve  as  a  trustworthy  guide." — London  Lancet. 

BOISLINIERE'S  OBSTETRIC  ACCIDENTS,  EMERGENCIES,  AND 
OPERATIONS. 
Obstetric  Accidents,  Emergencies,  and  Operations.     By  L.  Ch. 

BoiSLiNiERE,  M.D.,  late  Emeritus  Professor  of  Obstetrics,  St.  Louis 
Medical  College.    381  pages,  handsomely  illustrated.    Cloth,  ^2.00  net. 

"  It  is  clearly  and  concisely  written,  and  is  evidently  the  work  of  a  teacher  and  practi- 
tioner of  large  experience." — Bt-itish  Medical  Journal. 

"  A  manual  so  useful  to  the  student  or  the  general  practitioner  has  not  been  brought  to 
our  notice  in  a  long  time.  The  field  embraced  in  the  title  is  covered  in  a  terse,  interesting 
way." — Vale  Medical  Journal. 

BROCKWAY'S  MEDICAL  PHYSICS.     Second  Edition,  Revised. 
Essentials  of   Medical   Physics.     By   Fred  J.  Brockway,  M.D,, 
Assistant  Demonstrator  of  Anatomy  in  the  College  of  Physicians  and 
Surgeons,  New  York.     Crown  octavo,  330  pages  ;   155  fine  illustrations. 
Cloth,  $1.00  net ;   interleaved  for  notes,  ^1.25  net. 

[See  Samiders'  Question- Compends,  page  21.] 

"  The  student  who  is  well  versed  in  these  pages  will  certainly  prove  qualified  to  com- 
prehend with  ease  and  pleasure  the  great  majority  of  questions  involving  physical  principles 
likely  to  be  met  with  in  his  medical  studies." — American  Practitioner  and  News. 

"We  know  of  no  manual  that  affords  the  medical  student  a  better  or  more  concise 
exposition  of  physics,  and  the  book  may  be  commended  as  a  most  satisfactory  presentation 
of  those  essentials  that  are  requisite  in  a  course  in  medicine." — Nezv  York  Medical  Journal. 

*'  It  contains  all  that  one  need  know  on  the  subject,  is  well  written,  and  is  copiously 
illustrated." — Medical  Record,  New  York. 

BURR  ON  NERVOUS  DISEASES. 

A  Manual  of  Nervous  Diseases.  By  Charles  W,  Burr,  M.D., 
Clinical  Professor  of  Nervous  Diseases,  Medico-Chirurgical  College, 
Philadelphia ;  Pathologist  to  the  Orthopedic  Hospital  and  Infirmary 
for  Nervous  Diseases;  Visiting  Physician  to  St.  Joseph's  Hospital,  etc. 
Jn  Preparation. 


8  Medical  Publications  of  W.  B.  Saunders. 


BUTLER'S  MATERIA  MEDICA,  THERAPEUTICS,  AND  PHAR- 
MACOLOGY. 
A  Text-Book  of  Materia  Medica,  Therapeutics,  and  Pharma- 
cology. By  George  ¥.  Butler,  Ph.G.,  M.D.,  Professor  of  Materia 
Medica  and  of  Clinical  Medicine  in  the  College  of  Physicians  and 
Surgeons,  Chicago ;  Professor  of  Materia  Medica  and  Theraj^eutics, 
Northwestern  University,  Woman's  Medical  School,  etc.  Octavo,  858 
pages,  illustrated.     Cloth,  $4.00  net;    Sheep,  $5.00  net. 

"  Taken  as  a  whole,  the  book  may  fairly  be  considered  as  one  of  the  most  satisfactory 
of  any  single-volume  works  on  materia  medica  in  the  market." — Journal  of  the  American 
Medical  Association. 

"  The  work  is  executed  in  a  clear,  concise,  and  practical  manner,  and  should  meet  with 
a  hearty  endorsement  from  the  students  of  our  up-to-date  colleges.  The  book  will  l^e  found 
a  valuable  work  of  reference  for  the  practitioner." — Americati  j\Iedico-Surgical  Bulletin. 

CASSELBERRY  ON  THE  NOSE  AND  THROAT. 

Diseases  of  the  Nose  and  Throat.  By  W.  E.  Casselberry,  Pro- 
fessor of  Laryngology  and  Rhinology  in  the  Northwestern  University 
Medical  School,  Chicago.     In  Preparation. 

CERNA  ON  THE  NEWER  REMEDIES.  Second  Edition,  Revised. 
Notes  on  the  Newer  Remedies,  their  Therapeutic  Applications 
and  Modes  of  Administration.  By  David  Cerna,  M.D.,  Ph.D., 
formerly  Demonstrator  of  and  Lecturer  on  Experimental  Therapeutics 
in  the  University  of  Pennsylvania ;  Demonstrator  of  Physiology  in  the 
Medical  Department  of  the  University  of  Texas.  Rewritten  and 
greatly  enlarged.     Post-octavo,   253  pages.     Cloth,  $1.25. 

"These  '  Notes  '  will  be  found  v&ry  useful  to  practitioners  who  take  an  interest  in  the 
many  newer  remedies  of  the  present  day." — Edinburgh  Medical  Journal. 

"  The  appearance  of  this  new  edition  of  Dr.  Cerna's  verj'  valuable  work  shows  that  it 
is  properly  appreciated.  The  book  ought  to  be  in  the  possession  of  every  practising  physi- 
cian."— N'ew  York  Aledical  Journal. 

CHAPIN  ON  INSANITY. 

A  Compendium  of  Insanity.     By  John  B.  Chapin,  M.D.,  LL.D., 

Physician-in-Chief,  Pennsylvania  Hospital  for  the  Insane;  late  Physi- 
cian-Superintendent of  the  Willard  State  Hospital,  New  York ;  Hon- 
orary Member  of  the  Medico-Psychological  Society  of  Great  Britain, 
of  the  Society  of  Mental  Medicine  of  Belgium.     Cloth,  $1.25  net. 

The  author  has  given,  in  a  condensed  and  concise  form,  a  compendium  of  Diseases  of 
the  Mind,  for  the  convenient  use  and  aid  of  physicians  and  students.  The  work  will  also 
prove  valuable  to  members  of  the  legal  profession  and  to  those  who,  in  their  relations  to  the 
insane  and  to  those  supposed  to  be  insane,  often  desire  to  acquire  .some  practical  knowledge 
of  insanity  presented  in  a  form  that  may  be  understood  by  the  non -professional  reader. 

CHAPMAN'S  MEDICAL  JURISPRUDENCE  AND  TOXICOLOGY. 
Second  Edition,  Revised. 
Medical  Jurisprudence  and  Toxicology.  By  Henry  C.  Chapman, 
M.D.,  Professor  of  Institutes  of  Medicine  and  Medical  Jurisprudence 
in  the  Jefferson  Medical  College  of  Philadelphia.  254  pages,  with  55 
illustrations  and  3  full-page  plates  in  colors.     Cloth,  ^1.50  net. 

"The  best  book  of  its  class  for  the  undergraduate  that  we  know  of." — A^eiv  York 
Medical  Times. 


Medical  Publications  of  W.  B.  Saunders.  9 

CHURCH  AND  PETERSON'S  NERVOUS  AND  MENTAL  DISEASES. 
Nervous  and  Mental  Diseases.  By  Archibald  Church,  M.D., 
Professor  of  Mental  Diseases  and  Medical  Jurisprudence  in  the  North- 
western University  Medical  School,  Chicago ;  and  Frederick  Peter- 
son, M.D.,  Clinical  Professor  of  Mental  Dis^^ases  in  the  Woman's 
Medical  College,  New  York ;  Chief  of  Clinic,  Nervous  Department, 
College  of  Physicians  and  Surgeons,  New  York.     In  Preparation. 

CLARKSON'S  HISTOLOGY. 

A   Text=Book    of    Histology,    Descriptive   and    Practical.      By 

Arthur  Clarkson,  M.B.,  C.M.  Edin.,  formerly  Demonstrator  of 
Physiology  in  the  Owen's  College,  Manchester;  late  Demonstrator  of 
Physiology  in  Yorkshire  College,  Leeds.  Large  octavo,  554  pages; 
22  engravings  in  the  text,  and  174  beautifully  colored  original  illustra- 
tions.     Cloth,  strongly  bound,  $6.00  net. 

"  The  work  must  be  considered  a  valuable  addition  to  the  list  of  available  text  books, 
and  is  to  be  highly  recommended." — A^ew  York  Medical  Journal. 

"  This  is  one  of  the  best  works  for  students  we  have  ever  noticed.  We  predict  that  the 
book  will  attain  a  well-deserved  popularity  among  our  students." — Chicago  Medical  Recorder. 

"The  volume  is  a  most  valuable  addition  to  the  armamentarium  of  the  teacher." — 
Brooklyn  Medical  Journal. 

CLIMATOLOGY. 

Transactions  of  the  Eighth  Annual  Meeting  of  the  American 
Climatological  Association,  held  in  Washington,  September  22-25, 
1 89 1.  Forming  a  handsome  octavo  volume  of  276  pages,  uniform  with 
remainder  of  series.      (A  limited  quantity  only.)     Cloth,  $1.50. 

COHEN  AND  ESHNER'S  DIAGNOSIS. 

Essentials  of  Diagnosis.  By  Solomon  Solis-Cohen,  M.D.,  Pro- 
fessor of  Clinical  Medicine  and  Applied  Therapeutics  in  the  Philadel- 
phia Polyclinic  ;  and  Augustus  A.  Eshner,  M.D.,  Professor  of  Clinical 
Medicine  in  the  Philadelphia  Polyclinic.  Post-octavo,  382  pages;  55 
illustrations.      Cloth,  $1.50  net. 

[See  Saunders'   Question- Compends,  page   21.] 

"We  can  heartily  commend  the  book  to  all  those  who  contemplate  purchasing  a  'com- 
pend.'  It  is  modern  and  complete,  and  will  give  more  satisfaction  than  many  other  works 
which  are  perhaps  too  prolix  as  well  as  behind  the  times." — Medical  Review,  St.  Louis. 

CORWIN'S  PHYSICAL  DIAGNOSIS. 

Essentials  of  Physical  Diagnosis  of  the  Thorax.  By  Arthur 
AL  Corwin,  A.]\L,  M.D.,  Demonstrator  of  Physical  Diagnosis  in  Rush 
Medical  College,  Chicago  ;  Attending  Physician  to  Central  Free  Dis- 
pensary, Department  of  Rhinology,  Laryngology,  and  Diseases  of  the 
Chest,  Chicago.    200  pages,  illustrated.   Cloth,  flexible  covers,  $1.25  net. 

"  It  is  excellent.  The  student  who  shall  use  it  as  his  guide  to  the  careful  study  of 
physical  exploration  upon  normal  and  abnormal  subjects  can  scarcely  fail  to  acquire  a  good 
working  knowledge  of  the  subject." — Philadelphia  Polyclinic. 

"A  most  excellent  little  work.  It  brightens  the  memory  of  the  differential  diagnostic 
signs,  and  it  arranges  orderly  and  in  sequence  the  various  objective  phenomena  to  logical 
solution  of  a  careful  diagnosis." — Journal  of  Nervous  and  Mental  Diseases. 


10  Medical  Publications  of  W.  B.  Saunders. 


CRAGIN'S  QYN/CCOLOQY.     Fourth  Edition,  Revised. 

Essentials  of  Qynzecology.  liy  Edwin  ]].  Cragin,  M.D.,  Attend- 
ing (iyn;x;cologist,  Roosevelt  Hospital,  Out-Patients'  Department,  New 
York,  etc.  Crown  octavo,  200  pages;  62  fine  illustrations.  Cloth, 
$1.00;  interleaved  for  notes,  $1.25. 

[See  Saunders^  Question- Compe7ids,  page  21.] 

"  A  handy  volume,  and  a  distinct  improvement  on  students'  compends  in  general.  No 
autlior  wlio  was  not  himself  a  practical  gynecologist  could  have  consulted  the  student's  needs 
so  thoroughly  as  Dr.  Cragin  has  done." — Medical  Record,  New  York. 

CROOKSHANK'S  BACTERIOLOGY. 

A  Text=Book  of  Bacteriology.  By  Edgar  M.  Crookshank,  M.B., 
Professor  of  Comparative  Pathology  and  Bacteriology,  King's  College, 
London.  Octavo  volume  of  700  pages,  with  273  engravings  and  22 
original  colored  plates.     Cloth,  ^6.50  net;  Half  Morocco,  ^7.50  net. 

"  To  the  student  who  wishes  to  obtain  a  good  resume  of  what  has  been  done  in  bacteri- 
olog}',  or  who  wishes  an  accurate  account  of  the  various  methods  of  research,  the  book  mav 
be  recommended  with  confidence  that  he  will  find  there  what  he  requires." — Lotidon  Lancet. 

Da  COSTA'S  SURGERY.  Second  Ed.,  Revised  and  Greatly  Enlarged. 
Modern  Surgery,  General  and  Operative.  By  John  Chalmers 
DaCosta,  M.D.,  Clinical  Professor  of  Surgery,  Jefferson  Medical 
College,  Philadelphia ;  Surgeon  to  the  Philadelphia  Hospital,  etc. 
Handsome  octavo  volume  of  900  pages,  profusely  illustrated.  Cloth, 
$4.00  net;  Half  Morocco,  ^5.00  net. 

"We  know  of  no  small  work  on  surgery  in  the  English  language  which  so  well  fulfils 
the  requirements  of  the  modern  student." — Medico-Chirurgical Journal,  Bristol,  England. 

DE  SCHWEINITZ  ON  DISEASES  OF  THE  EYE.     Second  Edition, 
Revised. 
Diseases  of   the  Eye,     A  Handbook   of   Ophthalmic   Practice. 

By  G.  E.  DE  ScHWEiNiTZ,  M.D.,  Professor  of  Ophthalmology  in  the 
Jefferson  Medical  College,  Philadelphia,  etc.  Handsome  royal  octavo 
volume  of  679  pages,  with  256  fine  illustrations  and  2  chromo-litho- 
graphic  plates.     Cloth,  ^4.00  net;  Sheep  or  Half  Morocco,  ^5.00  net. 

"  A  clearly  written,  comprehensive  manual.  One  which  we  can  commend  to  students 
as  a  reliable  text-book,  written  with  an  evident  knowledge  of  the  wants  of  those  entering 
upon  the  study  of  this  special  branch  of  medical  science." — British  Medical  Journal. 

"  A  work  that  will  meet  the  requirements  not  only  of  the  specialist,  but  of  the  general 
practitioner  in  a  rare  degree.  I  am  satisfied  that  unusual  success  awaits  it." — William 
Pepper,  M.D.,  Professor  of  the  Theory  and  Practice  of  Medicine  and  Clinical  Medicine, 
University  of  Pennsylvania. 

DORLAND'S  OBSTETRICS. 

A  Manual  of  Obstetrics.  By  W.  A.  Newman  Borland,  M.D., 
Assistant  Demonstrator  of  Obstetrics,  LTniversity  of  Pennsylvania; 
Instructor  in  Gynecology  in  the  Philadelphia  Polyclinic.  760  pages; 
163  illustrations  in  the  text,  and  6  full-page  plates.      Cloth,  $2.50  net. 

"  By  far  the  best  book  on  this  subject  that  has  ever  come  to  our  notice." — American 
Medical  Review. 

"  It  has  rarely  been  our  duty  to  review  a  book  which  has  given  us  more  pleasure  in  its 
perusal  and  more  satisfaction  in  its  criticism.  It  is  a  veritable  encyclopedia  of  knowledge, 
a  gold  mine  of  practical,  concise  thoughts." — American  Medico-Surgical  Bulletin. 


Medical  Publications  of  W.  B.  Saunders.  11 

FROTHINQHAM'S  GUIDE  FOR  THE  BACTERIOLOGIST. 

Laboratory  Guide  for  the  Bacteriologist.  By  Langdon  Froth- 
INGHAM,  M.D.V.,  Assistant  in  Bacteriology  and  Veterinary  Science, 
Sheffield  Scientific  Schoo],  Yale  University.    Illustrated.    Cloth,  75  cts. 

"  It  is  a  convenient  and  useful  little  work,  and  will  more  than  repay  the  outlay  neces- 
sary for  its  purchase  in  the  saving  of  time  which  would  otherwise  be  consumed  in  looking 
up  the  various  points  of  technique  so  clearly  and  concisely  laid  down  in  its  pages." — Ameri- 
can Medico- Sia-gical  BtiUetin. 

GARRIGUES'  DISEASES  OF  WOMEN.  Second  Edition,  Revised. 
Diseases  of  Women.  By  Henry  J.  Garrigues,  A.M.,  M.D.,  Pro- 
fessor of  Gynecology  in  the  New  York  School  of  Clinical  Medicine; 
Gynecologist  to  St.  Mark's  Hospital  and  to  the  German  Dispensary, 
New  York  City,  etc.  Handsome  octavo  volume  of  728  pages,  illus- 
trated by  335  engravings  and  colored  plates.  Cloth,  $4.00  net; 
Sheep  or  Half  Morocco,  $5.00  net. 

"  One  of  the  best  text-books  for  students  and  practitioners  which  has  been  published  in 
the  English  language  ;  it  is  condensed,  clear,  and  comprehensive.  The  profound  learning 
and  great  clinical  experience  of  the  distinguished  author  find  expression  in  this  book  in  a 
most  attractive  and  instructive  form.  Young  practitioners  to  whom  experienced  consultants 
may  not  be  available  will  find  in  this  book  invaluable  counsel  and  help." — Thad.  A. 
Reamy,  M.D.,  LL.D.,  Professor  of  Clinical  Gynecology,  Medical  College  of  Ohio. 

GLEASON'S  DISEASES  OF  THE  EAR.  Second  Edition,  Revised. 
Essentials  of  Diseases  of  the  Ear.  By  E.  B.  Gleason,  S.B., 
M.D.,  Clinical  Professor  of  Otology,  Medico-Chirurgical  College, 
Philadelphia  ;  Surgeon-in-Charge  of  the  Nose,  Throat,  and  Ear  Depart- 
ment of  the  Northern  Dispensary,  Philadelphia.  208  pages,  with 
114  illustrations.  Cloth,  $1.00;  interleaved  for  notes,  ^1.25. 
[See  Saunders'  Question- Compends,  page  21.] 

"  It  is  just  the  book  to  put  into  the  hands  of  a  student,  and  cannot  fail  to  give  him  a 
useful  introduction  to  ear-affections  ;  while  the  style  of  question  and  answer  which  is  adopted 
throughout  the  book  is,  we  believe,  the  best  method  of  impressing  facts  permanently  on  the 
mind. ' ' — Liverpool  Medico-  Chirurgical  Journal. 

GOULD  AND  PYLE'S  CURIOSITIES  OF  MEDICINE. 

Anomalies  and  Curiosities  of  Medicine.  By  George  M.  Gould, 
M.D.,  and  Walter  L.  Pyle,  M.D.  An  encyclopedic  collection  of 
rare  and  extraordinary  cases  and  of  the  most  striking  instances  of 
abnormality  in  all  branches  of  Medicine  and  Surgery,  derived  from  an 
exhaustive  research  of  medical  literature  from  its  origin  to  the  present 
day,  abstracted,  classified,  annotated,  and  indexed.  Handsome  im- 
perial octavo  volume  of  968  pages,  with  295  engravings  in  the  text, 
and  12  full-page  plates.  Cloth,  $6.00  net;  Half  Morocco,  $7.00  net. 
Sold  by  Subscription. 

"  One  of  the  most  valuable  contributions  ever  made  to  medical  literature.  It  is,  so  far 
as  we  know,  absolutely  unique,  and  every  page  is  as  fascinating  as  a  novel.  Not  alone  for 
the  medical  profession  has  this  volume  value:  it  will  serve  as  a  book  of  reference  for  all  who 
are  interested  in  general  scientific,  sociologic,  or  medico-legal  topics." — Brooklyn  Medical 
Journal. 

"This  is  certainly  a  most  remarkable  and  interesting  volume.  It  stands  alone  among 
medical  literature,  an  anomaly  on  anomalies,  in  that  there  is  nothing  like  it  elsewhere  in 
medical  literature.  It  is  a  book  full  of  revelations  from  its  first  to  its  last  page,  and  cannot 
but  interest  and  sometimes  almost  horrify  its  readers." — American  Afedico- Surgical  Bulletin. 


12  Medical  Publications  of  W.  B.  Saunders. 


GRIFFIN'S  MATERIA  MEDICA  AND  THERAPEUTICS. 

Manual  of  Materia  Medica  and  Therapeutics.  By  Hi.nry  A. 
Griffin,  A. 15.,  M.l).,  Assistant  I'hysician  to  the  Roosevelt  Hospital, 
Out-Patient  Department,  New  York  City.      /;/  Preparation. 

GRIFFITH  ON  THE  BABY. 

The  Care  of  the  Baby.  By  J.  P.  Crozer  Griffith,  M.D.,  Clini- 
cal Professor  of  Diseases  of  Children,  University  of  Pennsylvania; 
Physician  to  the  Children's  Hospital,  Philadelphia,  etc.  i2mo,  392 
pages,  with  67  illustrations  in  the  text,  and  5  jilates.      Cloth,  $1.50. 

"  The  best  book  for  the  use  of  the  young  mother  with  which  we  are  acquainted.  .  .  . 
There  are  very  few  general  practitioners  who  could  not  read  the  book  througli  with  advan- 
tage. ' ' — Archives  of  Pediatrics. 

"The  whole  book  is  characterized  by  rare  good  sense,  and  is  evidently  written  by  a 
master  hand.  It  can  be  read  with  benefit  not  only  by  mothers  but  by  medical  students  and 
by  any  practitioners  who  have  not  had  large  opportunities  for  observing  children." — Anieri- 
cati  Journal  of  Obstetrics. 

GRIFFITH'S  WEIGHT  CHART. 

Infant's  Weight  Chart.  Designed  by  J.  P.  Crozer  Griffith,  M.  D.  , 
Clinical  Professor  of  Diseases  of  Children  in  the  University  of  Penn- 
sylvania, etc.      25  charts  in  each  pad.      Per  pad,  50  cents  net. 

A  convenient  blank  for  keeping  a  record  of  the  child's  weight  during  the  first  two  years 
of  life.  Printed  on  each  chart  is  a  curve  representing  the  average  weight  of  a  healthy  infant, 
so  that  any  deviation  from  the  normal  can  readily  be  detected. 

GROSS,  SAMUEL  D.,  AUTOBIOGRAPHY  OF. 

Autobiography  of  Samuel  D.  Gross,  M.D.,  Emeritus  Professor  of 
Surgery  in  the  Jefferson  Medical  College,  Philadelphia,  with  Remi- 
niscences of  His  Times  and  Contemporaries.  Edited  by  his  Sons, 
Samuel  W.  Gross,  M.D.,  LL.D.,  late  Professor  of  Principles  of  Sur- 
gery and  of  Clinical  Surgery  in  the  Jefferson  Medical  College,  and 
A.  Haller  Gross,  A.M.,  of  the  Philadelphia  Bar.  Preceded  by  a 
Memoir  of  Dr.  Gross,  by  the  late  Austin  Flint,  M.D.,  LL.D.  In 
two  handsome  volumes,  each  containing  over  400  pages,  demy  octavo, 
extra  cloth,  gilt  tops,  with  fine  Frontispiece  engraved  on  steel.  Price 
per  volume,  $2.50  net. 

"  Dr.  Gross  was  perhaps  the  most  eminent  exponent  of  medical  science  that  America 
has  yet  produced.  His  Autobiography,  related  as  it  is  with  a  fulness  and  completeness 
seldom  to  be  found  in  such  works,  is  an  interesting  and  valuable  book.  He  comments  on 
many  things,  especially,  of  course,  on  medical  men  and  medical  practice,  in  a  very  interest- 
ing way." — The  Spectator,  London,  England. 

HAMPTON'S  NURSING. 

Nursing:  Its  Principles  and  Practice.  By  Isabel  Adamg  Hamp- 
ton, Graduate  of  the  New  York  Training  School  for  Nurses  attached 
to  Bellevue  Hospital ;  Superintendent  of  Nurses,  and  Principal  of  the 
Training  School  for  Nurses,  Johns  Hopkins  Hospital,  Baltimore,  Md. 
i2mo,  484  pages,  profusely  illustrated.      Cloth,  $2.00  net. 

"  Seldom  have  we  perused  a  book  upon  the  subject  that  has  given  us  so  much  pleasure 
as  the  one  before  us.  We  would  strongly  urge  upon  the  members  of  our  own  profession  the 
need  of  a  book  like  this,  for  it  will  enable  each  of  us  to  become  a  training  school  in  him- 
self. ' ' — Ontario  Medical  Journal. 


Mediciil  Publications  of  W.  B.  Saunders.  13 

HARE'S  PHYSIOLOGY.     Third  Edition,  Revised. 

Essentials  of  Physiology.  By  H.  A.  Hare,  M.D.,  Professor  of 
Therapeutics  and  Materia  Medica  in  the  Jefferson  Medical  College  of 
Philadelphia;  Physician  to  the  Jefferson  Medical  College  Hospital. 
Containing  a  series  of  handsome  illustrations  from  the  celebrated 
**Icones  Nervorum  Capitis"  of  Arnold.  Crown  octavo,  239  pages. 
Cloth,  $1.00  net;  interleaved  for  notes,  $1.25  net. 

[See  Saufiders^  Question- Compends,  page  21.] 

"  The  best  condensation  of  physiological  knowledge  we  have  yet  seen." — Medical 
Record,  New  York. 

HART'S  DIET  IN  SICKNESS  AND  IN  HEALTH. 

Diet  in  Sickness  and  in  Health.  By  Mrs.  Ernest  Hart,  formerly 
Student  of  the  Faculty  of  Medicine  of  Paris  and  of  the  London  School 
of  Medicine  for  Women ;  with  an  Introduction  by  Sir  Henry 
Thompson,  F.R.C.S.,  M.D.,  London.  220  pages  ;  illustrated.  Cloth, 
$1.50. 

"  We  recommend  it  cordially  to  the  attention  of  all  practitioners ;  both  to  them  and  to 
their  patients  it  may  be  of  the  greatest  service." — Nezu  York  Medical  Journal. 

HAYNES'  ANATOMY. 

A  Manual  of  Anatomy.  By  Irving  S.  Haynes,  M.D.,  Adjunct 
Professor  of  Anatomy  and  Demonstrator  of  Anatomy,  Medical  Depart- 
ment of  the  New  York  University,  etc.  680  pages,  illustrated  with  42 
diagrams  in  the  text,  and  134  full-page  half-tone  illustrations  from 
original  photographs  of  the  author's  dissections.      Cloth,  $2.50  net. 

"  This  book  is  the  work  of  a  practical  in.structor — one  who  knows  by  experience  the 
requirements  of  the  average  student,  and  is  able  to  meet  these  requirements  in  a  very  satis- 
factory way.      The  book  is  one  that  can  be  commended." — Medical  Record,  New  York. 

HEISLER'S  EMBRYOLOGY. 

A  Text=Book  of  Embryology.  By  John  C.  Heisler,  M.D.,  Pro- 
fessor of  Anatomy  in  the  Medico-Chirurgical  College,  Philadelphia. 
In  Preparation. 

HIRST'S  OBSTETRICS. 

A  Text=Book  of  Obstetrics.  By  Barton  Cooke  Hirst,  M.D., 
Professor  of  Obstetrics  in  the  University  of  Pennsylvania,  In  Prepa- 
ration. 

HYDE  AND  MONTGOMERY  ON  SYPHILIS  AND  THE  VENEREAL 
DISEASES. 
Syphilis  and  the  Venereal  Diseases.  By  James  Nevins  Hyde, 
M.D.,  Professor  of  Skin  and  Venereal  Diseases,  and  Frank  H.  Mont- 
gomery, M.D.,  Lecturer  on  Dermatology  and  Genito-Urinary  Diseases 
in  Rush  Medical  College,  Chicago,  111.  618  pages,  profusely  illustrated. 
Cloth,  $2.50  net. 

"  We  can  commend  this  manual  to  the  student  as  a  help  to  him  in  his  study  of  venereal 
diseases. ' ' — Liverpool  Medico-  Chiriirgical  Journal. 

"The  best  student's  manual  which  has  appeared  on  the  subject." — St.  Louis  Medical 
and  Surgical  Journal. 


14  Medical  Publications  of  W.  B.  Saunders. 

JACKSON  AND  GLEASON'S  DISEASES  OF  THE  EYE,  NOSE,  AND 
THROAT.  Second  Edition,  Revised. 
Essentials  of  Refraction  and  Diseases  of  the  Eye.  By  Edward 
Jackson,  A.M.,  M.D.,  Professor  of  Diseases  of  the  Eye  in  the  Phila- 
delphia Polyclinic  and  College  for  Graduates  in  Medicine  ;  and — 
Essentials  of  Diseases  of  the  Nose  and  Throat.  By  E.  Bald- 
win Glkason,  M.D..  Surgeon-in-Charge  of  the  Nose,  Throat,  and 
Ear  Department  of  the  Northern  Dispensary  of  Philadeljihia.  Two 
volumes  in  one.  Crown  octavo,  290  pages;  124  illustrations.  Cloth, 
$1.00;  interleaved  for  notes,  $1.25. 

[See  Saunders''  Question- Compends,  page  21.] 

"  Of  great  value  to  the  beginner  in  these  branches.  The  authors  are  both  capable  men, 
and  know  what  a  student  most  needs." — Medical  Record,  New  York. 

KEATINQ'S  DICTIONARY.     Second  Edition,  Revised. 

A  New  Pronouncing  Dictionary  of  Medicine,  with  Phonetic 
Pronunciation,  Accentuation,  Etymology,  etc.  By  John  M. 
Keating,  M.D.,  LL.  D.,  Fellow  of  the  College  of  Physicians  of  Phila- 
delphia; Vice-President  of  the  American  Paediatric  Society;  Editor 
"Cyclopaedia  of  the  Diseases  of  Children,"  etc.;  and  Henry 
Hamilton,  Author  of  '-'A  New  Translation  of  Virgil's  ^neid  into 
English  Rhyme,"  etc.;  with  the  collaboration  of  J.  Chalmers  Da- 
Costa,  M.D.,  and  Frederick  A.  Packard,  M.D.  With  an  Appendix 
containing  Tables  of  Bacilli,  Micrococci,  Leucomai'nes,  Ptomaines; 
Drugs  and  Materials  used  in  Antiseptic  Surgery ;  Poisons  and  their 
Antidotes ;  Weights  and  Measures ;  Thermometric  Scales ;  New 
Official  and  Unofficial  Drugs,  etc.  One  volume  of  over  800  pages. 
Prices,  with  Denison's  Patent  Ready-Reference  Index:  Cloth,  $5.00 
net;  Sheep  or  Half  Morocco,  g6.oo  net;  Half  Russia,  $6.50  net. 
Without  Patent  Index:  Cloth,  $4.00  net;  Sheep  or  Half  Morocco, 
$5.00  net. 

"  I  am  much  pleased  with  Keating's  Dictionary,  and  shall  take  pleasure  in  recommend- 
ing it  to  my  classes." — Henry  M.  Lyman,  M.D.,  Professor  of  the  Frinciples  and  Fj-actice 
of  Medicine,  Rusk  Medical  College,  Chicago,  III. 

"  I  am  convinced  that  it  will  be  a  very  valuable  adjunct  to  my  study-table,  convenient 
in  size  and  sufficiently  full  for  ordinary  use." — C.  A.  Lindsley,  M.D.,  Professor  of  the 
Theory  and  Practice  of  Medicine,  Medical  Dept.    Yale  University . 

KEATINQ'S  LIFE  INSURANCE. 

How  to  Examine  for  Life  Insurance.  By  John  M.  Keating, 
M.D.,  Fellow  of  the  College  of  Physicians  of  Philadelphia;  Vice- 
President  of  the  American  Paediatric  Society  ;  Ex-President  of  the 
Association  of  Life  Insurance  Medical  Directors.  Royal  octavo,  211 
pages ;  with  two  large  half-tone  illustrations,  and  a  plate  prepared  by 
Dr.  McClellan  from  special  dissections;  also,  numerous  other  illustra- 
tions.    Cloth,  ^2.00  net. 

"  This  is  by  far  the  most  useful  book  which  has  yet  appeared  on  insurance  examination, 
a  subject  of  growing  interest  and  importance.  Not  the  least  valuable  portion  of  the  volume 
is  Part  II,  which  consists  of  instructions  issued  to  their  examining  physicians  by  twenty-four 
representative  companies  of  this  country.  If  for  these  alone,  the  book  should  be  at  the  right 
hand  of  every  physician  interested  in  this  special  branch  of  medical  science." — The  Medical 
News. 


Medical  Publications  of  W.  B.  Saunders.  15 

KEEN  ON  THE  SURGERY  OF  TYPHOID  FEVER. 

The   Surgical   Complications  and   Sequels  of   Typhoid    Fever. 

By  Wm.  W.  Keen,  M.D.,  LL.D.,  Professor  of  the  Principles  of  Sur- 
gery and  of  Clinical  Surgery,  Jefferson  Medical  College,  Philadelphia; 
Corresponding  ^Member  of  the  Societe  de  Chirurgie,  Paris ;  Honorary 
Member  of  the  Societe  Beige  de  Chirurgie,  etc.  Octavo  volume  of 
386  pages,  illustrated.      Cloth,  $3.00  net. 

This  monograph  is  the  only  one  in  any  language  covering  the  entire  subject  of  the 
Surgical  Complications  and  Sequels  of  Typhoid  P'ever.  It  will  prove  to  be  of  importance 
and  interest  not  only  to  the  general  surgeon  and  physician,  but  also  to  many  specialists — laryn- 
gologists,   gynecologists,  pathologists,  and  bacteriologists. 

KEEN'S  OPERATION  BLANK.  Second  Edition,  Revised  Form. 
An  Operation  Blank,  with  Lists  of  Instruments,  etc.  Required 
in  Various  Operations.  Prepared  by  W.  W.  Keen,  M.D.,  LL.D., 
Professor  of  the  Principles  of  Surgery  in  Jefferson  Medical  College, 
Philadelphia.  Price  per  pad,  containing  blanks  for  fifty  operations, 
50  cents  net. 

KYLE  ON  THE  NOSE  AND  THROAT. 

Diseases  of  the  Nose  and  Throat.  By  D.  Braden  Kyle,  M.D., 
Clinical  Professor  of  Laryngology  and  Rhinology,  Jefferson  Medical 
College,  Philadelphia;  Consulting  Laryngologist,  Rhinologist,  and 
Otologist,  St.  Agnes'  Hospital ;  Bacteriologist  to  the  Philadelphia 
Orthopedic  Hospital.     In  Preparatio7i. 

LAINE'S  TEMPERATURE  CHART. 

Temperature  Chart.  Prepared  by  D.  T.  Laine,  M.D.  Size  8  x  i2^Y2, 
inches.  A  conveniently  arranged  Chart  for  recording  Temperature, 
with  columns  for  daily  amounts  of  Urinary  and  Fecal  Excretions, 
Food,  Remarks,  etc.  On  the  back  of  each  chart  is  given  in  full  the 
method  of  Brand  in  the  treatment  of  Typhoid  Fever.  Price,  per  pad 
of  25  charts,  50  cents  net. 

"  To  the  busy  practitioner  this  chart  will  be  found  of  great  value  in  fever  cases,  and 
especially  for  cases  of  typhoid." — Indian  Lancet,  Calcutta. 

lockwood's  practice  of  medicine. 

A  Manual  of  the  Practice  of  Medicine.  By  George  Roe  Lock- 
WOOD,  M.D.,  Professor  of  Practice  in  the  Woman's  Medical  College 
of  the  New  York  Infirmary,  etc.  935  pages,  with  75  illustrations  in 
the  text,  and  22  full-page  plates.      Cloth,  ^2.50  net. 

"  Gives  in  a  most  concise  manner  the  points  essential  to  treatment  usually  enumerated 
in  the  most  elaborate  works." — Massachusetts  Medical  Journal. 

LONG'S  SYLLABUS  OF  GYNECOLOGY. 

A  Syllabus  of  Gynecology,  arranged  in  Conformity  with  ••  An 
American  Text=Book  of  Gynecology."  By  J.  W.  Long,  I\LD., 
Professor  of  Diseases  of  Women  and  Children,  Medical  College  of 
Virginia,  etc.      Cloth,  interleaved,  $1.00  net. 

"  The  book  is  certainly  an  admirable  risume  of  what  every  gynecological  student  and 
practitioner  should  know,  and  will  prove  of  value  not  only  to  those  who  have  the  '  American 
Text-Book  of  Gynecology,'  but  to  others  as  well." — Brooklyn  Medical  Journal. 


16  Medical  Publications  of  W.  B.  Saunders. 

MACDONALD'S  SURGICAL  DIAGNOSIS  AND  TREATMENT. 

Surgical  Diagnosis  and  Treatment.  By  J.  W.  Macdonald,  M.D. 
Edin.,  L.R.C.S.,  Edin.,  Professor  of  the  Practice  of  Surgery  and  of 
Clinical  Surgery  in  Hamline  University ;  Visiting  Surgeon  to  St. 
Barnabas'  Hospital,  Minneapolis,  etc.  Handsome  octavo  volume  of 
800  pages,  profusely  illustrated.  Cloth,  $5.00  net;  Half  Morocco, 
$6. CO  net. 

"  A  thorough  and  complete  work  on  surgical  diagnosis  and  treatment,  free  from  pad- 
ding, full  of  valuable  material,  and  in  accord  with  the  surgical  teaching  of  the  day." — JVie 
Medical  News,  New  York. 

"The  work  is  brimful  of  just  the  kind  of  practical  information  that  is  useful  alike  to 
students  and  practitioners.  It  is  a  pleasure  to  commend  the  book  because  of  its  intrinsic 
value  to  the  medical  practitioner." — Cincinnati  Lancet-Clinic. 

MALLORY  AND  WRIGHT'S  PATHOLOGICAL  TECHNIQUE. 

Pathological  Technique.  A  Practical  Manual  for  Laboratory  Work 
in  Pathology,  Bacteriology,  and  Morbid  Anatomy,  with  chapters  on 
Post-Mortem  Technique  and  the  Performance  of  Autopsies.  By  Frank 
B.  Mallory,  A.m.,  M.D.,  Assistant  Professor  of  Pathology,  Harvard 
University  Medical  School,  Boston;  and  James  H.  Wright,  A.M., 
M.D.,  Instructor  in  Pathology,  Harvard  University  Medical  School, 
Boston.  Octavo  volume  of  396  pages,  handsomely  illustrated.  Cloth, 
$2.50  net. 

"  I  have  been  looking  forward  to  the  publication  of  this  book,  and  I  am  glad  to  say  that 
I  find  it  to  be  a  most  useful  laboratory  and  post-mortem  guide,  full  of  practical  information, 
and  well  up  to  date." — William  H.  Welch,  Professor  of  Pathology,  Johns  Hopkins  Uni- 
versity, Baltimore,  Md. 

MARTIN'S  MINOR  SURGERY,  BANDAGING,  AND  VENEREAL 
DISEASES.  Second  Edition,  Revised. 
Essentials  of  Minor  Surgery,  Bandaging,  and  Venereal 
Diseases.  By  Edward  Martin,  A.M.,  M.D.,  Clinical  Professor  of 
Genito-Urinary  Diseases,  University  of  Pennsylvania,  etc.  Crown 
octavo,  166  pages,  with  78  illustrations.  Cloth,  $1.00  ;  interleaved  for 
notes,  $1.25. 

[See  Saunders'  Question- Compends,  page  21.] 

"A  very  practical  and  systematic  study  of  the  subjects,  and  shows  the  author's  famil- 
iarity with  the  needs  of  students." — Therapeutic  Gazette. 

MARTIN'S  SURGERY.     Sixth   Edition,  Revised. 

Essentials  of  Surgery.  Containing  also  Venereal  Diseases,  Surgi- 
cal Landmarks,  Minor  and  Operative  Surgery,  and  a  complete  de- 
scription, with  illustrations,  of  the  Handkerchief  and  Roller  Bandages. 
By  Edward  Martin,  A.M.,  M.D.,  Clinical  Professor  of  Genito- 
Urinary  Diseases,  University  of  Pennsylvania,  etc.  Crown  octavo,  338 
pages,  illustrated.  With  an  Appendix  containing  full  directions  for  the 
preparation  of  the  materials  used  in  Antiseptic  Surgery,  etc.  Cloth, 
$1.00;  interleaved  for  notes,  $1.25. 

[See  Saunders''  Question- Compends,  page  21.] 

"  Contains  all  necessary  essentials  of  modern  surgery  in  a  comparatively  small  space. 
Its  s'yle  is  interesting,  and  its  illustrations  are  admirable. " — Medical  and  Surgical  Reporter.  Kjf 


Medical  Publications  of  W.  B.  Saunders.  17 

MCFARLAND'S  PATHOGENIC  BACTERIA. 

Text=Book  upon  the  Pathogenic  Bacteria.  Specially  written 
for  Students  of  Medicine.  By  Joseph  McFarland,  M.D.,  Pro- 
fessor of  Pathology  and  Bacteriology  in  the  Medico-Chirurgical  College 
of  Philadelphia,  etc.  Octavo  volume  of  359  pages,  finely  illustrated. 
Cloth,  $2.50  net. 

"  Dr.  McFarland  has  treated  the  subject  in  a  systematic  manner,  and  has  succeeded  in 
presenting  in  a  concise  and  readable  form  the  essentials  of  bacteriology  up  to  date.  Alto 
gether,  the  book  is  a  satisfactory  one,  and  I  shall  take  pleasure  in  recommending  it  to  the 
students  of  Trinity  College." — H.  B.  Anderson,  M.D.  ,  Professor  of  Pathology  and  Bac- 
teriology, Trinity  Medical  College,  Toronto. 

MEIGS  ON  FEEDING  IN  INFANCY. 

Feeding  in  Early  Infancy.  By  Arthur  V.  Meigs,  M.D.  Bound 
in  limp  cloth,  flush  edges,  25  cents  net. 

"  This  pamphlet  is  worth  many  times  over  its  price  to  the  physician.  The  author's 
experiments  and  conclusions  are  original,  and  have  been  the  means  of  doing  much  good." — 
Medical  Bulletin. 

MOORE'S  ORTHOPEDIC  SURGERY. 

A  Manual  of  Orthopedic  Surgery.  By  James  E.  Moore,  M.D., 
Professor  of  Orthopedics  and  Adjunct  Professor  of  Clinical  Surgery, 
University  of  Minnesota,  College  of  Medicine  and  Surgery.  Octavo 
volume  of  356  pages,  handsomely  illustrated.     Cloth,  $2.50  net. 

A  practical  book  based  upon  the  author's  experience,  in  which  special  stress  is  laid 
upon  early  diagnosis,  and  treatment  such  as  can  be  carried  out  by  the  general  practitioner. 
The  teachings  of  the  author  are  in  accordance  with  his  belief  that  true  conservatism  is  to 
be  found  in  the  middle  course  between  the  surgeon  who  operates  too  frequently  and  the 

orthopedist  who  seldom  operates. 

MORRIS'S  MATERIA  MEDICA  AND  THERAPEUTICS.  Fourth 
Edition,  Revised. 
Essentials  of  Materia  Medica,  Therapeutics,  and  Prescription= 
Writing.  By  Henry  Morris,  M.D.,  late  Demonstrator  of  Thera- 
peutics, Jefferson  Medical  College,  Philadelphia,  Fellow  of  the  College 
of  Physicians,  Philadelphia,  etc.  Crown  octavo,  250  pages.  Cloth, 
^i.oo;  interleaved  for  notes,  $1.25. 

[See  Saunders'  Question- Compends,  page  21.] 

"  This  work,  already  excellent  in  the  old  edition,  has  been  largely  improved  by  revi 
sion. " — American  Practitioner  and  jVews. 

MORRIS,  WOLFF,  AND  POWELL'S  PRACTICE  OF  MEDICINE. 
Third  Edition,  Revised. 
Essentials  of  the  Practice  of  Medicine.  By  Henry  Morris,  M.  D., 
late  Demonstrator  of  Therapeutics,  Jefferson  Medical  College,  Phila- 
delphia ;  with  an  Appendi.x  on  the  Clinical  and  Microscopic  Examina- 
tion of  Urine,  by  Lawrence  Wolff,  M.D. ,  Demonstrator  of  Chemistry, 
Jefferson  Medical  College,  Philadelphia.  Enlarged  by  some  300  essen- 
tial formulae  collected  and  arranged  by  William  M.  Powell,  M.D. 
Post-octavo,  488  pages.      Cloth,  $2.00. 

[See  Saunders'   Question- Compends,  page  21.] 

"  The  teaching  is  sound,  the  presentation  graphic  ;  matter  full  as  can  be  desired,  and 
style  attractive." — American  Practitioner  and  jVews. 

2 


18  Medical  Publications  of  W,  B.  Saunders. 


MORTEN'S  NURSE'S  DICTIONARY. 

Nurse's  Dictionary  of  Medical  Terms  and  Nursing  Treat- 
ment. Containing  Definitions  of  the  Principal  Medical  and  Nursing 
Terms  and  Al)l)reviations ;  of  the  Instruments,  Drugs,  Diseases,  Acci- 
dents, Treatments,  Operations,  Foods,  Aj)pliances,  etc.  encountered 
in  the  ward  or  in  the  sick-room.  By  Honnor  Morten,  author  of 
"  How  to  Become  a  Nurse,"  etc.     i6mo,  140  pages.      Cloth,  $1.00. 

"  \  handy,  compact  little  volume,  containing  a  large  amount  of  general  information,  all 
of  which  is  arranged  in  dictionary  or  encyclopedic  form,  thus  facilitating  quick  reference. 
It  is  certainly  of  value  to  those  for  whose  use  it  is  published." — C/iica^o  Clinical  Review. 

NANCREDE'S  ANATOMY.     Fifth  Edition. 

Essentials  of  Anatomy,  including  the  Anatomy  of  the  Viscera. 
By  Charles  B.  Nancrede,  M.D.,  Professor  of  Surgery  and  of  Clini- 
cal Surgery  in  the  University  of  Michigan,  Ann  Arbor.  Crown  octavo, 
388  pages;  180  illustrations.  With  an  Appendix  containing  over  60 
illustrations  of  the  osteology  of  the  human  body.  Based  upon  Gray' s 
Anatomy.  Cloth,  $1.00;  interleaved  for  notes,  $1.25. 
[See  Saunders    Question- Co7tipends,  page  21.] 

"  For  self-quizzing  and  keeping  fresh  in  mind  the  knowledge  of  anatomy  gained  at 
school,  it  would  not  be  easy  to  speak  of  it  in  terms  too  favorable." — American  Practitioner. 

NANCREDE'S  ANATOMY  AND  DISSECTION.     Fourth  Edition. 
Essentials  of  Anatomy  and    Manual  of    Practical    Dissection. 

By  Charles  B.  Nancrede,  M.D.,  Professor  of  Surgery  and  of  Clinical 
Surgery,  University  of  Michigan,  Ann  Arbor.  Post-octavo;  500  pages, 
with  full-page  lithographic  plates  in  colors,  and  nearly  200  illustrations. 
Extra  Cloth  (or  Oilcloth  for  the  dissection-room),  ^2.00  net. 

"  It  may  in  many  respects  be  considered  an  epitome  of  Gray's  popular  work  on  general 
anatomy,  at  the  same  time  having  some  distinguishing  characteristics  ot  its  own  to  commend 
it.  The  plates  are  of  more  than  ordinary  excellence,  and  are  of  especial  value  to  students 
in  their  work  in  the  dissecting  room." — Journal  of  the  American  Medical  Association. 

NORRIS'S  SYLLABUS  OF  OBSTETRICS.  Third  Edition,  Revised. 
Syllabus  of  Obstetrical  Lectures  in  the  Medical  Department 
of  the  University  of  Pennsylvania.  By  Richard  C.  Norris, 
A.M.,  M.D.,  Demonstrator  of  Obstetrics,  University  of  Pennsylvania. 
Crown  octavo,  222  pages.      Cloth,  interleaved  for  notes,  $2.00  net. 

"This  work  is  so  far  superior  to  others  on  the  same  subject  that  we  take  pleasure  in 
calling  attention  briefly  to  its  excellent  features.  It  covers  the  subject  thoroughly,  and  will 
prove  invaluable  both  to  the  student  and  the  practitioner." — Medical  Record,  New  York. 

PENROSE'S  DISEASES  OF  WOMEN.     Second  Edition,  Revised. 
A  Text=Book  of  Diseases  of  Women.     By  Charles  B.  Penrose, 
M.D.,  Ph.D.,  Professor  of  Gynecology  in  the  University  of  Pennsyl- 
vania;   Surgeon    to   the   Gynecean    Hospital,    Philadelphia.     Octavo 
volume  of  529  pages,  handsomely  illustrated.      Cloth,  $3.50  net. 

"I  shall  value  very  highly  the  copy  of  Penrose's  'Diseases  of  Women'  received. 
I  have  already  recommended  it  to  my  class  as  THE  BEST  book." — Howard  A.  Kelly, 
Professor  of  Gynecology  and  Obstetrics,  Johns  Hopkins  University,  Baltimore,  Md. 

"  The  book  is  to  be  commended  without  reserve,  not  only  to  the  student  but  to  the 
general  practitioner  who  wishes  to  have  the  latest  and  best  modes  of  treatment  explained 
with  absolute  clearness."- — Therapeutic  Gazette. 


Medical  Publications  of  W.  B.  Saunders.  19 


POWELL'S  DISEASES  OF  CHILDREN.     Second  Edition. 

Essentials  of  Diseases  of  Children.  By  William  M.  Powell, 
M.D.,  Attending  Physician  to  the  Mercer  House  for  Invalid  Women 
at  Atlantic  City,  N.  j.  ;  late  Physician  to  the  Clinic  for  the  Diseases  of 
Children  in  the  Hospital  of  the  University  of  Pennsylvania.  Crown 
octavo,  222  pages.     Cloth,  $i.oo;  interleaved  for  notes,  $1.25. 

[See  Saiinders'   Question- Compends,  page   21.] 

"Contains  the  gist  of  all  the  best  works  in  the  department  to  which  it  relates." — 
American  Practitioner  and  A'ews. 

PRINQLE'S  SKIN  DISEASES  AND  SYPHILITIC  AFFECTIONS. 
Pictorial  Atlas  of  Skin  Diseases  and  Syphilitic  Affections 
(American  Edition).  Translation  from  the  French.  Edited  by 
1.  J.  Pringle,  M.B.,  F.R.C.P.,  Assistant  Physician  to  the  Middlesex 
Hospital,  London.  Photo-lithochromes  from  the  famous  models  in 
the  Museum  of  the  Saint-Louis  Hospital,  Paris,  with  explanatory  wood- 
cuts and  text.  In  12  Parts.  Price  per  Part,  $3.00.  Complete  in 
one  volume,  Half  Morocco  binding,  $40.00  net. 

"  I  strongly  recommend  this  Atlas.  The  plates  are  exceedingly  well  executed,  and 
will  be  of  great'value  to  all  studying  dermatology." — STEPHEN  Mackenzie,  M.D. 

"The  introduction  of  explanatory  wood-cuts  in  the  text  is  a  novel  and  most  important 
feature  which  greatly  furthers  the  easier  understanding  of  the  excellent  plates,  than  which 
nothing,  we  venture  to  say,  has  iieen  seen  better  in  point  of  correctness,  beauty,  and  general 
merit." — Nezu  York  Medical  Journal. 

PYE'S  BANDAGING. 

Elementary  Bandaging  and  Surgical  Dressing.  With  Direc- 
tions concerning  the  Immediate  Treatment  of  Cases  of  Emergency. 
For  the  use  of  Dressers  and  Nurses.  By  Walter  Pye,  F.R.C.S.,  late 
Surgeon  to  St.  Mary's  Hospital,  London.  Small  i2mo,  with  over  80 
illustrations.      Cloth,  flexible  covers,  75  cents  net. 

"  The  directions  are  clear  and  the  illustrations  are  good.'' ^— ^London  Lancet. 
"The  author  writes  well,  the  diagrams  are  clear,  and  the  book  itself  is  small  and  port- 
able, although  the  paper  and  type  are  good." — British  Medical  Journal. 

RAYMOND'S  PHYSIOLOGY. 

A  Manual  of  Physiology.  By  Joseph  H.  Raymond,  A.M.,  M.D., 
Professor  of  Physiology  and  Hygiene  and  Lecturer  on  Gynecology  in 
the  Long  Island  College  Hospital ;  Director  of  Physiology  in  the 
Hoagland  Laboratory,  etc.  382  pages,  with  102  illustrations  in  the 
text,  and  4  full -page  colored  plates.      Cloth,  $1.25  net. 

"  Extremely  well  gotten  up,  and  the  illustrations  have  been  selected  with  care.  The 
text  is  fully  abreast  with  modern  physiology." — British  Medical  Journal. 

RONTGEN  RAYS. 

Archives  of  the  Rontgen  Ray  (Formerly  Archives  of  Clinical 
Skiagraphy).  Edited  by  Sydney  Rowland,  M.A.,  M.R.C.S.,  and 
W.  S.  Hedley,  M.D.,  M.R.C.S.  A  series  of  collotype  illustrations, 
with  descriptive  text,  illustrating  the  applications  of  the  new  photo- 
graphy to  INIedicine  and  Surgery.  Price  per  Part,  $1.00.  Now  ready: 
Vol.  I.,  Parts  I.  to  IV.;  Vol.  II.,  Parts  I.,  II. 


Saunders' 
Question 
compends 


Arranged  in  Question  and 
Answer  Form> 

np'HE  MOST  COMPLETE  AND  BEST 
ILLUSTRATED  SERIES  OF 

COMPENDS  EVER  ISSUED. 


Now  the  Standard  Authorities  in  Medical  Literature  .  .  .  ♦ 

with  Students  and  Practitioners  in  every  City  of  the  United  States  and  Canada. 


CL- 


OVER J  65,000  COPIES  SOLD. 


-<^ 


THE  REASON  WHY. 

They  are  the  advance  guard  of  "Student's  Helps" — that  DO  help.  They  are  the 
leaders  in  their  special  line,  well  and  authoritatively  written  by  able  men,  who,  as  teachers  in 
the  large  colleges,  know  exactly  what  is  wanted  by  a  student  preparing  for  his  examinations. 
The  judgment  exercised  in  the  selection  of  authors  is  fully  demonstrated  by  their  professional 
standing.  Chosen  from  the  ranks  of  Demonstrators,  Quiz-masters,  and  Assistants,  most  of 
them  have  become  Professors  and  Lecturers  in  their  respective  colleges. 

Each  book  is  of  convenient  size  (5x7  inches),  containing  on  an  average  250  pages, 
profusely  illustrated,  and  elegantly  printed  in  clear,  readable  type,  on  fine  paper. 

The  entire  series,  numbering  twenty-three  volumes,  has  been  kept  thoroughly  revised 
and  enlarged  when  necessary,  many  of  the  books  being  in  their  fifth  and  sixth  editions. 

TO  SUM  UP. 

Although  there  are  numerous  other  Quizzes,  Manuals,  Aids,  etc.  in  the  market,  none  of 
them  approach  the  "  Blue  Series  of  Question  Compends  ;"  and  the  claim  is  made  for  the 
following  points  of  excellence  : 

1.  Professional  distinction  and  reputation  of  i^uthors. 

2.  Conciseness,  clearness,  and  soundness  of  treatment. 

3.  Quality  of  illustrations,  paper,  printing,  and  binding. 

Any  of  these  Compends  w^ill  be  mailed  on  receipt  of  price  (see  next  page  for  List). 


Oaunders^  (^uestion-Compend  Oeries* 

Price,  Cloth,  $1.00  per  copy,  except  when  otherwise  noted. 


"Where   the  work   of  preparing  students'  manuals   is   to  end  we   cannot   say,  but   the 
Saunders  Series,  in  our  opinion,  bears  oft"  the  pahn  at  present."— AVzt/  Yo7k  Medical  Record. 


1.  ESSENTIALS  OF  PHYSIOLOGY.     By  H.  A.   Hare,  ]M.D.     Third   edition, 

revised  and  enlarged.      (Si-oo  net.) 

2.  ESSENTIALS   OF    SURGERY.     By  Edward  Martin,  ]\I.D.      Sixth  edition. 

revised,  with  an  Appendi.\  on  Antiseptic  Surgery. 

3.  ESSENTIALS   OF    ANATOMY.      By  Charles   B.    Nancrede,   M.D.     Fifth 

edition,  with  an  Appendix. 

4.  ESSENTIALS  OF  MEDICAL  CHEMISTRY,  ORGANIC  AND  INORGANIC. 

By  Lawrence  Wolff,  M.D.      Fourth  edition,  revised,  with  an  Appendix. 

5.  ESSENTIALS  OF  OBSTETRICS.     By  W.  E.\sterly  Ashton,  M.D.     Fourth 

edition,  revised  and  enlarged. 

6.  ESSENTIALS  OF   PATHOLOGY  AND  MORBID  ANATOMY.     By  C.  E. 

Ar>ljlND  Semple,  M.D. 

7.  ESSENTIALS  OF   MATERIA  MEDICA,  THERAPEUTICS,  AND   PRE- 

SCRIPTION=WRITING.    By  Henry  Morris,  M.D.     Fourth  edition,  revised. 

8.  9.    ESSENTIALS   OF    PRACTICE    OF    MEDICINE.      By  Henry   Morris, 

^LD.  An  Appendix  on  Ukine  E.xamination.  By  Lawrence  Wolff,  M.D. 
Third  edition,  enlarged  by  some  300  Essential  Formula;,  selected  from  eminent 
authorities,  by  Wm.  I\L  Powell,  M.D.     (Double  number,  S2.00.) 

10.  ESSENTIALS  OF  GYN/ECOLOGY.      By  Edwin  B.  Cr.\gin,  M.D.      Fourth 

edition,  revised. 

11.  ESSENTIALS  OF  DISEASES  OF  THE  SKIN.     By  Henry  W.  Stelwagon, 

M.D.     Third  edition,  revised  and  enlarged.      (Si. 00  net.) 

12.  ESSENTIALS  OF  MINOR  SURGERY,  BANDAGING,  AND  VENEREAL 

DISEASES.      By  Edward  ^L\RTIN,  ^LD.     Second  ed.,  revised  and  enlarged. 

13.  ESSENTIALS  OF  LEGAL  MEDICINE,  TOXICOLOGY,  AND  HYGIENE. 

By  C.  E.  Armand  Semple,  jM.D. 

14.  ESSENTIALS  OF   DISEASES  OF  THE   EYE,  NOSE,  AND  THROAT. 

By  Edward  Jackson,  ^LD. ,  and  E.  B.  Gleason,  M.D.     Second  ed.,  revised. 

15.  ESSENTIALS  OF  DISEASES  OF  CHILDREN.     By  William  M.  Powell, 

^LD.      Second  edition. 

16.  ESSENTIALS   OF   EXAMINATION   OF   URINE.     By   Lawrence  Wolff, 

I\LD.      Colored  "  Vogel  Scale."      (75  cents. ) 

17.  ESSENTIALS  OF  DIAGNOSIS.     By  S.  Solis  Cohen,  M.D.,  and  A.  A.  Eshner, 

^LD.      (Si. 50  net.) 

18.  ESSENTIALS  OF  PRACTICE   OF   PHARMACY.     By   Lucius    E.    Sayre. 

Second  edition,  revised  and  enlarged. 

20.  ESSENTIALS  OF  BACTERIOLOGY.     By  M.  V.  Ball,  I\LD.     Third  edition, 

revised. 

21.  ESSENTIALS  OF  NERVOUS  DISEASES  AND  INSANITY.     By  John  C. 

Shaw,  ^LD.      Third  edition,  revised. 

22.  ESSENTIALS  OF   MEDICAL  PHYSICS.      By   Fred  J.    Brockway,    M.D. 

Second  edition,  revised.      {Si. 00  net.) 

23.  ESSENTIALS  OF  MEDICAL  ELECTRICITY.    By  David  D.  Stewart,  M.D., 

and  Edward  S.  Lawrance.  ISI.D. 

24.  ESSENTIALS  OF  DISEASES  OF  THE   EAR.      By  E.  B.  Gleason,  M.D. 

Second  edition,  revised  and  greatly  enlarged. 


Pamphlet  containing  specimen  pages,  etc.  sent  free  upon  application* 


Saunders^ 

New  Series 
of  Manuals 


for  Students 
and 
Practitioners* 


'T'HAT  there  exists  a  need  for  thoroughly  reliable  hand-books  on  the  leading  branches 
of  Medicine  and  Surgery  is  a  fact  amply  demonstrated  by  the  favor  with  which 
the  SAUNDERS  NE"^  SERIES  OF  MANUALS  have  been  received  by  medical 
students  and  practitioners  and  by  the  Medical  Press,  These  manuals  are  not  merely 
condensations  from  present  literature,  but  are  ably  written  by  well-known  authors 
and  practitioners,  most  of  them  being  teachers  in  representative  American  colleges. 
Each  volume  is  concisely  and  authoritatively  written  and  exhaustive  in  detail,  w^ithout 
being  encumbered  with  the  introduction  of  "cases,"  which  so  largely  expand  the 
ordinary  text-book.  These  manuals  will  therefore  form  an  admirable  collection  of 
advanced  lectures,  useful  alike  to  the  medical  student  and  the  practitioner:  to  the 
latter,  too  busy  to  search  through  page  after  page  of  elaborate  treatises  for  what  he 
wants  to  know,  they  will  prove  of  inestimable  value ;  to  the  former  they  will  afford 
safe  guides  to  the  essential  points  of  study. 

The  SAUNDERS  NEW  SERIES  OF  MANUALS  are  conceded  to  be  superior 
to  any  similar  books  now  on  the  market.  No  other  manuals  afford  so  much  infor- 
mation in  such  a  concise  and  available  form.  A  liberal  expenditure  has  enabled  the 
publisher  to  render  the  mechanical  portion  of  the  w^ork  w^orthy  of  the  high  literary 
standard  attained  by  these  books. 

Any  of  these  Manuals  w^ill  be  mailed  on  receipt  of  price  (see  next  page  for  List), 


Saunders^  New  Series  of  Manuals* 


VOLUMES   PUBLISHED. 

PHYSIOLOGY.  By  Joseph  Howard  Raymond,  A.M.,  M.D.,  Professor  of  Physiology 
and  Hygiene  and  Lecturer  on  Gynecology  in  the  Long  Island  College  Hospital ; 
Director  of  Physiology  in  the  Hoagland  Laboratory,  etc.     Illustrated.     Cloth,  $1.25  net. 

SURGERY,  General  and  Operative.  By  John  Chalmers  DaCosta,  M.D.  ,  Clini- 
cal Professor  of  Surgery,  Jefferson  Medical  College,  Philadelphia;  Surgeon  to  the 
Philadelphia  Hospital,  etc.  Second  edition,  thoroughly  revised  and  greatly  enlarged. 
(Jctavo,  900  pages,  profusely  illustrated.      Cloth,  $4.00  net  ;   Half  Morocco,  $5-°°  '^^^• 

DOSE=BOOK    AND    MANUAL    OF    PRESCRIPTI0N=WR1TING.      By   E.    Q. 

Thornton,  M.D.,  Demonstrator  of  Therapeutics,  Jefferson  Medical  College,  Phila- 
delphia.    Illustrated.     Cloth,  ^1.25  net. 

SURGICAL  ASEPSIS.  By  Carl  Beck,  M.D.,  Surgeon  to  St.  Mark's  Hospital  and 
to  the  New  York  German  Poliklinik,  etc.     Illustrated.     Cloth,  $1.25  net. 

MEDICAL  JURISPRUDENCE.  By  Henry  C.  Chapman,  M.D.  Professor  of  Insti- 
tutes of  Medicine  and  Medical  Jurisprudence  in  the  Jefferson  Medical  College  of  Phila- 
delphia.    Illustrated.     Cloth,  ;?i.50  net. 

SYPHILIS  AND  THE  VENEREAL  DISEASES.  By  James  Nevins  Hyde,  M.D., 
Professor  of  Skin  and  Venereal  Diseases,  and  Frank  H.  MONTGOMERY,  M.D., 
Lecturer  on  Dermatology  and  Genito-Urinary  Diseases  in  Rush  Medical  College, 
Chicago.      Profusely  illustrated.      (Double  number.)     Cloth,  $2.50  net. 

PRACTICE  OF  MEDICINE.  By  George  Roe  Lockwood,  M.D.,  Professor  of 
Practice  in  the  Woman's  Jvledical  College  of  the  New  York  Infirmary ;  Instructor  in 
Physical  Diagnosis  in  the  Medical  Department  of  Columbia  College,  etc.  Illustrated. 
(Double  number.)     Cloth,  ^2. 50  net. 

MANUAL  OF  ANATOMY.  By  Irving  S.  Haynes,  M.D.,  Adjunct  Professor  of 
Anatomy  and  Demonstrator  of  Anatomy,  Medical  Department  of  the  New  York 
University,  etc.      Beautifully  illustrated.      (Double  Number. )     Cloth,  ^2.50  net. 

MANUAL  OF  OBSTETRICS.  By  W.  A.  Newman  Dorland,  M.D.,  Assistant 
Demonstrator  of  Obstetrics,  University  of  Pennsylvania ;  Chief  of  Gynecological  Dis- 
pensaiy,  Pennsylvania  Hospital,  etc.  Profusely  illustrated.  (Double  number.)  Cloth, 
;^2.50  net. 

DISEASES  OF  WOMEN.  By  J.  Bland  Sutton,  F.R.C.S.,  Assistant  Surgeon  to 
Middlesex  Hospital  and  Surgeon  to  Chelsea  Hospital,  London  ;  and  Arthur  E. 
Giles,  M.D.,  B..Sc.  Lond. ,  F.R.C.S.  Edin.,  Assistant  Surgeon  to  Chelsea  Hospital, 
London.     Handsomely  illustrated.     (Double  number.)     Cloth,  ^2.50  net. 


VOLUMES  IN  PREPARATION. 

NOSE  AND  THROAT.  By  D.  Braden  Kyle,  M.D.,  Clinical  Professor  of  Laryn- 
gology and  Rhinology,  Jefferson  Medical  College,  Philadelphia;  Consulting  Laryngolo- 
gist,  Rhinologist,  and  Otologist,  St.  Agnes'  Hospital ;  Bacteriologist  to  the  Philadel- 
phia Orthopedic  Hospital  and  liifirmary  for  Nervous  Diseases,  etc. 

NERVOUS  DISEASES.  By  Charles  W.  Burr,  M.D.,  Clinical  Professor  of  Nervous 
Diseases,  Medico-Chirurgical  College.  Philadelphia ;  Pathologist  to  the  Orthopaedic 
Hospital  and  Infirmary  for  Nervous  Diseases ;  Visiting  Physician  to  the  St.  Joseph 
Hospital,  etc. 

***  There  will  be  published  in  the  same  series,  at  short  intervals,  carefully-prepared  works 
on  various  subjects  by  prominent  specialists. 


Pamphlet  containing  specimen  pages^  etc.  sent  free  upon  application. 


24  Medical  Publications  of  W.  B.  Saunders. 

SAUNDBY'S  RENAL  AND  URINARY  DISEASES. 

Lectures  on  Renal  and  Urinary  Diseases.  By  Robert  Saundby, 
M.D.  Kclin.,  Fellow  of  the  Royal  College  of  Physicians,  London,  and 
of  the  Royal  Medico-Chirurgical  Society  ;  Physician  to  the  General 
Hospital  ;  Consulting  Physician  to  the  Eye  Hospital  and  to  the  Hos- 
pital for  Diseases  of  Women;  Professor  of  Medicine  in  Mason  College, 
Birmingham,  etc.  Octavo  volume  of  434  pages,  with  numerous  illus- 
trations and  4  colored  plates.     Cloth,  $2.50  net. 

"  The  volume  makes  a  favorable  impression  at  once.  The  style  is  clear  and  succinct. 
We  cannot  find  any  part  of  the  subject  in  which  the  views  expressed  are  not  carefully  thought 
out  and  fortified  by  evidence  drawn  from  the  most  recent  sources.  The  book  may  be  cordially 
recommended." — British  Medical  Journal. 

SAUNDERS'  POCKET  MEDICAL  FORMULARY.     Fourth  Edition, 
Revised. 

By  William  M.  Powell,  M.D.,  Attending  Physician  to  the  Mercer 
House  for  Invalid  Women  at  Atlantic  City,  N.  J.  Containing  1750 
formulae  selected  from  the  best-known  authorities.  With  an  Appen- 
dix containing  Posological  Table,  Formulae  and  Doses  for  Hypo- 
dermic Medication,  Poisons  and  their  Antidotes,  Diameters  of  the 
Female  Pelvis  and  Fcetal  Head,  Obstetrical  Table,  Diet  List  for  Various 
Diseases,  Materials  and  Drugs  used  in  Antiseptic  Surgery,  Treatment 
of  Asphyxia  from  Drowning,  Surgical  Remembrancer,  Tables  of 
Incompatibles,  Eruptive  Fevers,  Weights  and  Measures,  etc.  Hand- 
somely bound  in  flexible  morocco,  with  side  index,  wallet,  and  flap. 
$1.75  net. 

"  This  little  book,  that  can  be  conveniently  carried  in  the  pocket,  contains  an  immense 
amount  of  material.  It  is  very  useful,  and,  as  the  name  of  the  author  of  each  prescription 
is  given,  is  unusually  reliable." — Medical  Record,  New  York. 

SAUNDERS'  POCKET  MEDICAL  LEXICON.  Fourth  Edition, 
Revised. 
A  Dictionary  of  Terms  and  Words  used  in  Medicine  and 
Surgery.  By  John  M.  Keating,  M.D.,  Fellow  of  the  College  of 
Physicians  of  Philadelphia;  Editor  of  the  "Cyclopaedia  of  Diseases 
of  Children,"  etc.;  Author  of  the  "New  Pronouncing  Dictionary  of 
Medicine;"  and  Henry  Hamilton,  Author  of  "  A  New  Translation 
of  Virgil's  yEneid  into  English  Verse;"  Co-Author  of  the  "New 
Pronouncing  Dictionary  of  Medicine."  321110,  280  pages.  Cloth, 
75  cents;  Leather  Tucks,  $1.00. 

"  Remarkably  accurate  in  terminology,  accentuation,  and  definition." — Journal  of  the 
American  Medical  Association. 

SAYRE'S  PHARMACY.     Second  Edition,  Revised. 

Essentials  of  the  Practice  of  Pharmacy.  By  Lucius  E.  Sayre, 
M.D.,  Professor  of  Pharmacy  and  Materia  Medica  in  the  University  of 
Kansas.  Crown  octavo,  200  pages.  Cloth,  $1.00;  interleaved  for 
notes,  $1.25. 

[See  Saunders'  Question- Cotnpends,  page  21.] 

"  The  topics  are  treated  in  a  simple,  practical  manner,  and  the  work  forms  a  very  useful 
student's  manual." — Boston  Medical  and  Surgical  Journal. 


Medical  Publications  of  W.  B.  Saunders.  25 

SEMPLE'S  LEGAL  MEDICINE,  TOXICOLOGY,  AND  HYGIENE. 
Essentials  of    Legal    Medicine,  Toxicology,  and   Hygiene.     By 

C.  E.  Armand  Semple,  B.  A.,  M.  B.  Cantab.,  M.  R.  C.  P.  Lond., 
Physician  to  the  Northeastern  Hospital  for  Children,  Hackney,  etc. 
Crown  octavo,  2 1 2  pages ;  130  illustrations.  Cloth,  $1.00;  interleaved 
for  notes,  S 1 . 2  5 . 

[See  Saunders'  Question- Compends,  page  21.] 

"  No  general  practitioner  or  student  can  afford  to  be  without  this  valuable  work.  The 
subjects  are  dealt  with  by  a  masterly  hand." — London  Hospital  Gazette. 

SEMPLE'S  PATHOLOGY  AND  MORBID  ANATOMY. 

Essentials    of    Pathology    and    Morbid    Anatomy.      By  C.   E. 

Armand  Semple,  B.A.,  M.B.  Cantab.,  M.R. C.P.  Lond.,  Physician  to 
the  Northeastern  Hospital  for  Children,  Hackney,  etc.     Crown  octavo, 
174  pages;  illustrated.      Cloth,  $1.00;  interleaved  for  notes,  $1.25. 
[See  Satinders'  Question-  Compends,  page  21.] 

"  Should  take  its  place  among  the  standard  volumes  on  the  bookshelf  of  both  student 
and  practitioner." — London  Lfospital  Gazette. 

SENN'S  GENITO=URINARY  TUBERCULOSIS. 

Tuberculosis  of  the  Genito-Urinary  Organs,  Male  and  Female. 

By  Nicholas  Senn,  M.D.,  Ph.D.,  LL.D.,  Professor  of  the  Practice  of 
Surgery  and  of  Clinical  Surgery,  Rush  Medical  College,  Chicago. 
Handsome  octavo  volume  of  320  pages,  illustrated.     Cloth,  ^3.00  net. 

"  An  important  book  upon  an  important  subject,  and  written  by  a  man  of  mature  judg- 
ment and  wide  experience.  The  author  has  given  us  an  instructive  book  upon  one  of  the 
most  important  subjects  of  the  day." — Clinical  Reporter. 

"  A  work  which  adds  another  to  the  many  obligations  the  profession  owes  the  talented 
author." — Chicago  ALedical  Recorder. 

SENN'S  SYLLABUS  OF  SURGERY. 

A  Syllabus  of  Lectures  on  the  Practice  of  Surgery,  arranged 
in  conformity  with  "  An  American  Text=Book  of  Surgery."    By 

Nicholas  Senn,  M.D.,  Ph.D.,  Professor  of  the  Practice  of  Surgery  and 
of  Clinical  Surgery  in  Rush  Medical  College,  Chicago.     Cloth,  $2.00. 

"  This  syllabus  will  be  found  of  service  by  the  teacher  as  well  as  the  student,  the  work 
being  superbly  done.  There  is  no  praise  too  high  for  it.  No  surgeon  should  be  without 
it. " — Ne-iv  York  Medical  Times. 

SENN'S  TUMORS. 

Pathology  and  Surgical  Treatment  of  Tumors.  By  N.  Senn, 
M.D.,  Ph.D.,  LL.D.,  Professor  of  Surgery  and  of  Clinical  Surgery, 
Rush  Medical  College ;  Professor  of  Surgery,  Chicago  Polyclinic ; 
Attending  Surgeon  to  Presbyterian  Hospital ;  Surgeon-in-Chief,  St. 
Joseph's  Hospital,  Chicago.  Octavo  volume  of  710  pages,  with  515 
engravings,  including  full-page  colored  plates.  Cloth,  $6.00  net; 
Half  Morocco,  $7.00  net. 

"  The  most  exhaustive  of  any  recent  book  in  English  on  this  subject.  It  is  well  illus- 
trated, and  will  doubtless  remain  as  the  principal  monograph  on  the  subject  in  our  language 
for  some  years.  The  book  is  handsomely  illustrated  and  printed,  and  the  author  has  given  a 
notable  and  lasting  contribution  to  surgery." — Journal  of  the  American  Medical  Association. 


26  Medical  Publications  of  W.  B.  Saunders. 


SHAW'S  NERVOUS  DISEASES  AND  INSANITY.  Third  Edition, 
Revised. 
Essentials  of  Nervous  Diseases  and  Insanity.  By  John  C. 
Shaw,  M.D.,  Clinical  Professor  of  Diseases  of  the  Mind  and  Nervous 
System,  Long  Island  College  Hospital  Medical  School ;  Consulting 
Neurologist  to  St.  Catherine's  Hospital  and  to  the  Long  Island  College 
Hospital.  Crown  octavo,  i86  pages;  48  original  illustrations.  Cloth, 
$1.00  ;  interleaved  for  notes,  $1.25. 

[See  Saunders'  Question- Compends,  page  21.] 

"Clearly  and  intelligently  written." — Boston  Aledical  and  Surgical  Journal. 

"There  is  a  mass  of  valuable  material  crowded  into  this  small  compass." — American 
3fedico- Surgical  Bulletin. 

STARR'S  DIETS  FOR  INFANTS  AND  CHILDREN. 

Diets  for  Infants  and  Children  in  Health  and  in  Disease.     By 

Louis  Starr,  M.D.,  Editor  of  "An  American  Text-Book  of  the 
Diseases  of  Children."  230  blanks  (pocket-book  size),  perforated 
and  neatly  bound  in  flexible  morocco.      $1.25  net. 

The  first  series  of  blanks  are  prepared  for  the  first  seven  months  of  infant  life  ;  each 
blank  indicates  the  ingredients,  but  not  the  quantities,  of  the  food,  the  latter  directions  being 
left  for  the  physician.  After  the  seventh  month,  modifications  being  less  necessary,  the  diet 
lists  are  printed  in  full.      Formulae  for  the  preparation  of  diluents  and  foods  are  appended. 

STELW AGON'S  DISEASES  OF  THE  SKIN.  Third  Edition,  Revised. 
Essentials  of  Diseases  of  the  Skin.  By  Henry  W.  Stelwagon, 
M.D.,  Clinical  Professor  of  Dermatology  in  the  Jefferson  Medical 
College,  Philadelphia;  Dermatologist  to  the  Philadelphia  Hospital; 
Physician  to  the  Skin  Department  of  the  Howard  Hospital,  etc. 
Crown  octavo,  270  pages;  86  illustrations.  Cloth,  $1.00  net;  inter- 
leaved for  notes,  $1.25  net. 

[See  Saunders'  Question- Cotnpetids,  page  21.] 

"  The  best  student's  manual  on  skin  diseases  we  have  yet  seen." — Times  and  Register. 

STENGEL'S  PATHOLOGY. 

A  Manual  of  Pathology.  By  Alfred  Stengel,  M.D.,  Physician 
to  the  Philadelphia  Hospital ;  Professor  of  Clinical  Medicine  in  the 
Woinan's  Medical  College  ;  Physician  to  the  Children's  Hospital  ; 
late  Pathologist  to  the  German  Hospital,  Philadelphia,  etc.  In 
Preparation. 

STEVENS'   MATERIA    MEDICA    AND   THERAPEUTICS.      Second 
Edition,  Revised. 
A  Manual  of   Materia   Medica   and  Therapeutics.      By  A.  A. 

Stevens,  A.M.,  M.D.,  Lecturer  on  Terminology  and  Instructor  in 
Physical  Diagnosis  in  the  University  of  Pennsylvania;  Demonstrator 
of  Pathology  in  the  Woman's  Medical  College  of  Philadelphia.  Post- 
octavo,  445  pages.      Cloth,  $2.25. 

"The  author  has  faithfully  presented  modern  therapeutics  in  a  comprehensive  work, 
and,  while  intended  particularly  for  the  use  of  students,  it  will  be  found  a  reliable  guide  and 
sufficiently  comprehensive  for  the  physician  in  practice." — University  Medical  AJagazine. 


Medical  Publications  of  W.  B.  Saunders.  27 

STEVENS'  PRACTICE  OF  MEDICINE.  Fourth  Edition,  Revised. 
A  Manual  of  the  Practice  of  Medicine.  By  A.  A.  Stevens,  A.M., 
M.D.,  Lecturer  on  Terminology  and  Instructor  in  Physical  Diagnosis 
in  the  University  of  Pennsylvania ;  Demonstrator  of  Pathology  in 
the  Woman's  Medical  College  of  Philadelphia.  Specially  intended 
for  students  preparing  for  graduation  and  hospital  examinations.  Post- 
octavo,  511  pages;  illustrated.      Flexible  leather,  $2.50. 

"The  frequency  with  which  new  editions  of  this  manual  are  demanded  bespeaivs  its 
popularity.  It  is  an  excellent  condensation  of  the  essentials  of  medical  practice  for  the 
student,  and  maybe  found  also  an  excellent  reminder  for  the  busy  physician." — Buffalo 
Medicixl  Journal. 

STEWART'S  PHYSIOLOGY. 

A  Manual  of  Physiology,  with  Practical  Exercises.  For 
Students  and  Practitioners.  By  G.  N.  Stewart,  M.A.,  M.D., 
D.Sc,  lately  Examiner  in  Physiology,  University  of  Aberdeen,  and 
of  the  New  Museums,  Cambridge  University ;  Professor  of  Physiology 
in  the  Western  Reserve  University,  Cleveland,  Ohio.  Octavo  volume 
of  800  pages;  278  illustrations  in  the  text,  and  5  colored  plates. 
Cloth,  $3.50  net. 

"  It  will  make  its  way  by  sheer  force  of  merit,  and  amply  deserves  to  do  so.  It  is  one 
of  the  very  best  English  text-books  on  the  subject." — London  Lancet. 

"Of  the  many  text-books  of  physiology  published,  we  do  not  know  of  one  that  so 
nearly  comes  up  to  the  ideal  as  does  Prof.  Stewart's  volume." — British  Medical  Journal. 

STEWART  AND  LAWRANCE'S  MEDICAL  ELECTRICITY. 

Essentials  of  Medical  Electricity.  By  D.  D.  Stewart,  M.D., 
Demonstrator  of  Diseases  of  the  Nervous  System  and  Chief  of  the 
Neurological  Clinic  in  the  Jefferson  Medical  College;  and  E.  S. 
Lawrance,  M.D.,  Chief  of  the  Electrical  Clinic  and  Assistant  Demon- 
strator of  Diseases  of  the  Nervous  System  in  the  Jefferson  Medical 
College,  etc.  Crown  octavo,  158  pages;  65  illustrations.  Cloth, 
$1.00  ;  interleaved  for  notes,  $1.25. 

[See  Saunders''  Qiiestion-Cotnpetids,  page  21.] 

"  Throughout  the  whole  brief  space  at  their  command  the  authors  show  a  discriminating 
knowledge  of  their  subject." — Medical  News. 

STONEY'S  NURSING.     Second  Edition,  Revised. 

Practical  Points  in  Nursing.     For  Nurses  in  Private  Practice. 

By  Emily  A.  M.  Stoney,  Graduate  of  the  Training-School  for  Nurses, 
Lawrence,  Mass.;  late  Superintendent  of  the  Training-School  for 
Nurses,  Carney  Hospital,  South  Boston,  Mass.  456  pages,  illustrated 
with  73  engravings  in  the  text,  and  8  colored  and  half-tone  plates. 
Cloth,  $1.75  net. 

"  There  are  few  books  intended  for  non-professional  readers  which  can  be  so  cordially 
endorsed  by  a  medical  journal  as  can  this  one."  —  Therapeutic  Gazette. 

"  This  is  a  well-written,  eminently  practical  volume,  which  covers  the  entire  range  of 
private  nursing  as  distinguished  from  hospital  nursing,  and  instructs  the  nurse  how  best  to 
meet  the  various  emergencies  which  may  arise,  and  how  to  prepare  everything  ordinarily 
needed  in  the  illness  of  her  patient." — American  Jourjial  of  Obstetrics  and  Diseases  of 
Women  and  Children. 

"  It  is  a  work  that  the  physician  can  place  in  the  hands  of  his  private  nurses  with  the 
assurance  of  benefit." — Ohio  Medical  Journal. 


28  Medical  Piihlications  of  W.  B.  Saunders. 

SUTTON  AND  GILES'  DISEASES  OF  WOMEN. 

Diseases  of  Women.  By  J.  Bland  Sutton,  F.R.C.S.,  Assistant 
Surgeon  to  Middlesex  Hospital,  and  Surgeon  to  Chelsea  Hospital, 
London;  and  Arthur  E.  Giles,  M.D.,  B.Sc.  Lond.,  F.R.C.S.  Edin., 
Assistant  Surgeon  to  Chelsea  Hospital,  London.  436  pages,  hand- 
somely illustrated.      Cloth,  $2.50  net. 

"  The  book  is  very  well  prepared,  and  is  certain  to  be  well  received  by  the  medical 
public. ' ' — British  Medical  Journal. 

"The  text  has  been  carefully  prepared.  Nothing  essential  has  been  omitted,  and  its 
teachings  are  those  recommended  by  the  leading  authorities  of  the  day." — Journal  of  the 
Aiiitiican  Medical  Assoiiation. 

THOMAS'S  DIET  LISTS  AND  SICK=ROOM  DIETARY. 

Diet  Lists  and  Sick=Rooni  Dietary.  By  Jerome  B.  Thomas, 
M.D.,  Visiting  Physician  to  the  Home  for  Friendless  Women  and 
Children  and  to  the  Newsboys'  Home  ;  Assistant  Visiting  Physician 
to  the  Kings  County  Hospital.  Cloth,  $1.50.  Send  for  sample  sheet. 
"  The  idea  is  good,  and  the  lists  are  copious." — London  Lancet. 

"Its  practical  usefulness  places  it  among  the  requirements  of  every  practitioner." — 
Chicago  Medical  Recorder. 

THORNTON'S  DOSE=BOOK  AND  PRESCRIPTION=WRITING. 

Dose=Book  and  Manual  of    Prescription=Writing.       By   E.    Q. 

Thornton,  M.D.,  Demonstrator  of  Therapeutics,  Jefferson  Medical 
College,  Philadelphia.      334  pages,  illustrated.      Cloth,  ^1.25  net. 

"  Full  of  practical  suggestions;  will  take  its  place  in  the  front  rank  of  works  of  this 
sort." — Medical  Record,  New  York. 

VAN  VALZAH  AND  NISBET'S  DISEASES  OF  THE  STOMACH. 
Diseases  of  the  Stomach.  By  William  W.  Van  Valzah,  M.D.  , 
Professor  of  General  Medicine  and  Diseases  of  the  Digestive  System 
and  the  Blood,  New  York  Polyclinic;  and  J.  Douglas  Nisbet,  M.D., 
Adjunct  Professor  of  General  Medicine  and  Diseases  of  the  Digestive 
System  and  the  Blood,  New  York  Polyclinic.  Octavo  volume  of  674 
pages,  illustrated.      Cloth,  $3.50  net. 

VIERORDT'S  MEDICAL  DIAGNOSIS.  Third  Edition,  Revised. 
Medical  Diagnosis.  By  Dr.  Oswald  Vierordt,  Professor  of  Medi- 
cine at  the  University  of  Heidelberg.  Translated,  with  additions, 
from  the  second  enlarged  German  edition,  with  the  author's  permission, 
by  Francis  H.  Stuart,  A.M.,  M.D.  Handsome  royal  octavo  volume 
of  700  pages;  178  fine  wood-cuts  in  te.xt,  many  of  them  in  colors. 
Cloth,  $4.00  net;  Sheep  or  Half  Morocco,  $5.00  net;  Half  Russia, 
$5.50  net. 

"  A  treasury  of  practical  information  which  will  be  found  of  daily  use  to  every  busy 
practitioner  who  will  consult  it." — C.  A.  LiNDSLEY,  M.D.,  Professor  of  the  Theory  and 
Practice  of  Medicine,   Yale  University. 

"  Rarely  is  a  book  published  with  which  a  reviewer  can  find  so  little  fault  as  with  the 
volume  before  us.  Each  particular  item  in  the  consideration  of  an  organ  or  apparatus,  which 
is  necessary  to  determine  a  diagnosis  of  any  disease  of  that  organ,  is  mentioned;  nothing 
seems  forgotten.  The  chapters  on  diseases  of  the  circulatoiy  and  digestive  apparatus  and 
nervous  system  are  especially  full  and  valuable.  The  reviewer  would  repeat  that  the  book  is 
one  of  the  best — probably  the  best — which  has  fallen  into  his  hands." — University  Aledical 
Magazifie. 


Medical  Piihlications  of  W.  B.  Saunders.  29 

WARREN'S  SURGICAL  PATHOLOGY  AND  THERAPEUTICS. 

Surgical  Pathology  and  Therapeutics.  By  John  Collins  Warren, 
M.D.,  LL.D.,  Professor  of  Surgery,  Medical  Department  Harvard 
University;  Surgeon  to  the  Massachusetts  General  Hospital,  etc. 
Handsome  octavo  volume  of  832  pages;  136  relief  and  lithographic 
illustrations,  33  of  which  are  printed  in  colors,  and  all  of  which  were 
drawn  by  William  J.  Kaula  from  original  specimens.  Cloth,  $6.00 
net;  Half  Morocco,  $7.00  net. 

"There  is  the  work  of  Dr.  Warren,  which  I  think  is  the  most  creditable  book  on 
Surgical  Pathology,  and  the  most  beautiful  medical  illustration  of  the  bookmaker's  art,  that 
has  ever  been  issued  from  the  American  press." — Dr.  Roswell  Park,  zn  the  Harvard 
Graduate  Magazine. 

"  The  handsomest  specimen  of  bookmaking  that  has  ever  been  issued  from  the  American 
medical  press." — Atnerica^i  Journal  of  the  Medical  Sciences. 

"A  most  striking  and  very  excellent  feature  of  this  book  is  its  illustrations.  Without 
exception,  from  the  point  of  accuracy  and  artistic  merit,  they  are  the  best  ever  seen  in  a  work 
of  this  kind.  Many  of  those  representing  microscopic  pictures  are  so  perfect  in  their  coloring 
and  detail  as  almost  to  give  the  beholder  the  impression  that  he  is  looking  down  the  barrel 
of  a  microscope  at  a  well-mounted  section." — Annals  of  Surgery. 

WEST'S  NURSING. 

An  American  Text=Book  of  Nursing.  By  American  Teachers. 
Edited  by  Roberta  M.  West,  late  Superintendent  of  Nurses  in  the 
Hospital  of  the  University  of  Pennsylvania.     In  Preparation. 

WOLFF  ON  EXAMINATION  OF  URINE. 

Essentials  of  Examination  of  Urine.  By  Lawrence  Wolff,  M.D., 
Demonstrator  of  Chemistry,  Jefferson  Medical  College,  Philadelphia, 
etc.  Colored  (Vogel)  urine  scale  and  numerous  illustrations.  Crown 
octavo.      Cloth,  75  cents. 

[See  Saii?iders'   Question- Compends,  page   21.] 
'*  A  very  good  work  of  its  kind — very  well  suited  to  its  purpose." — Times  and  Register. 

WOLFF'S  MEDICAL  CHEMISTRY.     Fourth  Edition,  Revised. 
Essentials    of    Medical    Chemistry,   Organic    and    Inorganic. 

Containing  also  Questions  on  Medical  Physics,  Chemical  Physiology, 
Analytical    Processes,    Urinalysis,    and    Toxicology.      By   Lawrence 
Wolff,  M.D.,  Demonstrator  of  Chemistry,  Jefferson  Medical  College. 
Philadelphia,  etc.      Crown  octavo,   218  pages.      Cloth,  ^i.oo;   intf 
leaved  for  notes.  Si. 25. 

[See  Saunders'  Question- Compends,  page   21.] 

•'The  scope  of  this  work  is  certainly  equal  to  that  of  the  best  course  of  lectures  on 
Medical  Chemistry." — Phari/tacetttical  Era. 


CLASSIFIED    LIST 


Medical  Publications 


W.  B.  SAUNDERS, 

925  Walnut  Street,  Philadelphia. 


ANATOMY,  EMBRYOLOGY, 
HISTOLOGY. 

Clarkson — A  Text-Book  of  Histology,  9 
Haynes — A  Manual  of  Anatomy,  .  .  .  13 
Heisler — A  'i'ext-Rook  of  Embryology,  13 
Nancrede — Essentials  of  Anatomy,  .  .  18 
Nancrede — Essentials  of  Anatomy  and 

Manual  of  Practical  Dissection,  .  .  .  18 
Semple — Essentials   of   Pathology  and 

Morbid  Anatomy, 25 

BACTERIOLOGY. 

Ball — Essentials  of  Bacteriology,  ...      6 
Crookshank — A  Text-Book  of  Bacteri- 
ology,   10 

Frothingham  —  Laboratory  Guide,  .  .  H 
Mallory    and    Wright  —  Pathological 

Technique, 16 

McFarland — Pathogenic  Bacteria,    .    .    17 

CHARTS,  DIET-LISTS,  ETC. 

Griffith — Infant's  Weight  Chart,     ...  12 

Hart — Diet  in  Sickness  and  in  Health,  .  13 

Keen — Operation  Blank, 15 

Laine — Temperature  Chart 15 

Meigs — Feeding  in  Early  Infancy,     .    .  17 

Starr — Diets  for  Infants  and  Children,  .  26 
Thomas — Diet-Lists     and    Sick-Room 

Dietary, 28 

CHEMISTRY  AND  PHYSICS. 

Brockway — Essentials  of  Medical  Phys- 
ics,   7 

Wolff — Essentials  of  Medical  Chemistry,   29 

CHILDREN. 

An  American  Text-Book  of  Diseases 

of  Children,    .    .             3 

Griffith — Care  of  the  Baby 12 

Griffith — Infant's  Weight  Chart,   ...  12 

Meigs — Feeding  in  Early  Infancy,    .    .  17 

Powell — Essentials  of  Dis.  of  Children,  19 

Siarr — Diets  for  Infants  and  Children,  .  26 

DIAGNOSIS. 

Cohen  and  Eshner— Essentials  of  Di- 
agnosis,           .      9 

Corwin — Physical  Diagnosis,      ....      9 

Macdonald — Surgical  Diagnosis  and 
Treatment,      16 

Vierordt — Medical  Diagnosis,    ....    28 

DICTIONARIES. 

Keating — Pronouncing  Dictionary,    .    .  I4 

Morten — Nurse's  Dictionary,      ....  18 

Saunders'  Pocket  Medical  Lexicon,      .  24 


EYE,  EAR,  NOSE,  AND  THROAT. 

An  American  Text- Book  of  Diseases 

of  tlie  Eye,  Ear,  Nose,  and  Throat,  .  3 
Casselberry — Dis.  of  Nose  and  Throat,  8 
De  Schweinitz — -Diseases  of  the  Eye, .  ID 
Gleason — Essentials  of  Dis.  of  the  Ear,  il 
Jackson   and    Gleason — Essentials  of 

Diseases  of  the  Eye,  Nose,  and  Throat,  14 
Kyle — Diseases  of  the  Nose  and  Throat,  15 

GENITO=URINARY. 

An  American  Text-Book  of  (Jenito- 
Urinary  and  Skin  Diseases, 4 

Hyde  and  Montgomery — Syphilis  and 
the  \'enereal  Diseases, 13 

Martin — Essentials  of  Minor  Surgery. 
Bandaging,  and  Venereal  Diseases,     .    16 

Saundby — Renal  and  Urinary  Diseases,  24 

Senn — Genito-Urinary  Tuberculosis,     .    25 

GYNECOLOGY. 

American  Text- Book  of  Gynecology,  4 
Cragin — Essentials  of  Gynecology,  .  .  10 
Garrigues — Diseases  of  Women,  ...  11 
Long — Syllabus  of  Gynecology,  ...  15 
Penrose — Diseases  of  Women,  ....  18 
Sutton  and  Giles — Diseases  of  Women,  28 

MATERIA  MEDICA,  PHARMACOL- 
OGY, AND  THERAPEUTICS. 

An  American  Text-Book  of  Applied 

Therapeutics 3 

Butler — Text-Book  of  Materia  Medica, 

Therapeutics  and  Pharmacology,  ...  8 
Cerna — Notes  on  the  Newer  Remedies,  8 
Griffin — Materia  Med.  and  Therapeutics,  12 
Morris — Essentials  of   Materia   Medica 

and  Therapeutics,  .    .  1 7 

Saunders'  Pocket  Medical  Formulary,  24 
Sayre — Essentials  of  Pharmacy,  .    .    24 

Stevens — Essentials  of  Materia  Medica 

and  Therapeutics ...    26 

Thornton — Dose-Book  and    Manual   of 

Prescription-Writing 28 

\A^arren — Surgical  Pathology  and  Ther- 
apeutics,       29 

MEDICAL   JURISPRUDENCE    AND 
TOXICOLOGY. 

An  American  Text-Book  of  Legal 
Medicine  and  Toxicology, 4 

Chapman — Medical  Jurisprudence  and 
Toxicology, 8 

Semple — Essentials  of  Legal  Medicine, 
Toxicology,  and  Hygiene, 25 


Medical  Publications  of  W.  B.  Saunders. 


31 


NERVOUS  AND  MENTAL 
DISEASES,  ETC. 

Burr — Nervous  Diseases, 7 

Chapin — Compendium  of  Insanity,  .  .  8 
Church    and    Peterson — Nervous  and 

Mental  Diseases, 9 

Shaw — Essentials  of  Nervous  Diseases 

and  Insanity, 26 

NURSING. 

An  American  Text-Book  of  Nursing,  29 

Griffith — The  Care  of  the  Baby,    ...  12 

Hampton — Nursing, 12 

Hart — Diet  in  Sickness  and  in  Health,  13 

Meigs — Feeding  in  Early  Infancy,     .    .  17 

Morten — Nurse's  Dictionary iS 

Stoney — Practical  Points  in  Nursing,    .  27 

OBSTETRICS. 

An  American  Text-Book  of  Obstetrics,  4 
Ashton — Essentials  of  Obstetrics,  ...  6 
Boisliniere  — Obstetric  Accidents,  Emer- 
gencies, and  Operations, 7 

Borland -Manual  of  Obstetrics,    .    .    .  lo 

Hirst — Text-Book  of  Olistetrics,    ...  13 

Norris — Syllabus  of  Obstetrics,  ....  18 

PATHOLOGY. 

An  American  Text-Book  of  Pathologj',  5 
Mallory    and    Wright  —  Pathological 

Technique, 16 

Semple — Essentials   of    Pathology  and 

Morbid  Anatomy, 25 

Senn — Pathology  and  Surgical  Treat- 
ment of  Tumors,        25 

Stengel — Manual  of  Pathology,     ...    26 
Warren — Surgical  Pathology  and  Thera- 
peutics,    29 

PHYSIOLOGY. 

An  American  Text-Book  of  Physi- 
ology,        5 

Hare — Essentials  of  Physiology,  ...  13 
Raymond — Manual  of  Physiology,  .  .  I9 
Stewart — Manual  of  Physiology,  ...    27 

PRACTICE  OF  MEDICINE. 

An  American  Text-Book  of  the  The- 
ory and  Practice  of  Medicine,  ....      5 

An  American  Year-Book  of  Medicine 
and  Surgery,  6 

Anders — Te.\t-Book  of  the  Practice  of 
Medicine, ....      6 

Lockwood — Manual  of  the  Practice  of 
Medicine,    .    .  ....    15 

Morris — Essentials  of  the  Practice  of 
Medicine, 17 

Rowland  and  Hedley  —  Archives  of 
the  Roentgen  Ray, I9 

Stevens — Manual  of  the  Practice  of 
Medicine, 27 

SKIN  AND  VENEREAL. 

An  American  Text-Book  of  Genito- 
urinary and  Skin  Diseases, 3 


Hyde  and  Montgomery — Syphilis  and 
the  \'enereal  Diseases, 13 

Martin — Essentials  of  Minor  Surger}', 
Bandaging,  and  Venereal  Diseases,    .    16 

Pringle — Pictorial  Atlas  of  Skin  Dis- 
eases and  Syphilitic  Affections,    ...    19 

Stelwagon — Essentials  of  Diseases  of 
the  Skin 26 

SURGERY. 

An  American  Text-Book  of  Surgery,  5 
An  American  Year-Book  of  Medicine 

and  Surgery, 6 

Beck — Manual  of  Surgical  Asepsis,  .    .  7 

DaCosta — Manual  of  Surgery,  ....  10 

Keen— Operation  Blank,     ......  15 

Keen — The  Surgical  Complications  and 

-Sequels  of  Typhoid  Fever, 15 

Macdonald — Surgical    Diagnosis    and 

Treatment,          16 

Martin — Essentials   of    Minor  Surgery, 

Bandaging,  and  Venereal  Diseases,     .  16 

Martin — Essentials  of  Surgery,  ....  16 

Moore^Orthopedic  Surgery, 17 

Pye — Elementary  Bandaging  and  Surgi- 
cal Dressing, ig 

Rowland    and    Hedley— Archives  of 

the  Roentgen  Ray, 19 

Senn — Genito-Urinary  Tuberculosis,     .  25 

Senn  —  Syllabus  of  Surgery, 25 

Senn — Pathology  and  Surgical  Treat- 
ment of  Tumors, 25 

Warren — Surgical  Pathology  and  Ther- 
apeutics,        29 

URINE  AND  URINARY  DISEASES. 

Saundby — Renal  and  Urinary  Diseases,  24 
Wolff — Essentials    of    Examination    of 
Urine, 29 

MISCELLANEOUS. 

Bastin — Laboratory  E.\ercises  in  Bot- 
any,      7 

Gould  and  Pyle — Anomalies  and  Curi- 
osities of  Medicine, 11 

Keating — How  to  E.xamine  for  Life 
Insurnnce,       14 

Keen — Surgical  Complicat'ons  and  Se- 
quels of  Ty]jhoid  Fever,       15 

Rowland  and  Hedley — Archives  of 
the  Roentgen  Ray, 19 

Saunders'  Medical  Hand-Atlases,    .    .       2 

Saunders'  New  Series  of  Manuals,    22,  23 

Saunders'  Pocket  Medical  Formulary,  .    24 

Saunders'  Question-Compends,     .    .  20,  21 

Senn — Pathology  and  Surgical  Treat- 
ment of  Tumors,    ...  .  -25 

Stewart  and  Lawrance — Essentials  of 
Medical  Electricity, 27 

Thornton — Dose-Book  and  Manual  of 
Prescription-Writing 28 

Van  Valzah  and  Nisbet — Diseases  of 
the  Stomach, 28 


In  Preparation  for  Early  Publication. 


AN  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  THE  EYE,  EAR,  NOSE, 
AND  THROAT. 

Edited  by  G.  E.  DK  Schweinitz,  M.D.  ,  Professor  of  Ophthalmology  in  the  Jeffer- 
son Medical  College,  I'liiladelphia ;  and  B.  Alexander  Randall,  M.D.,  Professor 
of  Diseases  of  the  Ear  in  the  University  of  Pennsylvania  and  in  the  Philadelphia 
Polyclinic. 

AN  AMERICAN  TEXT=BOOK  OF  PATHOLOGY. 

Edited  by  John  GuixfeRAS,  M.D.,  Professor  of  General  Pathology  and  of  Morbid 
Anatomy  in  the  University  of  Pennsylvania;  and  David  Riesman,  M. D.,  Demon- 
strator of  Pathological  Histology  in  the  University  of  Pennsylvania. 

AN  AMERICAN  TEXT-BOOK  OF  LEGAL  MEDICINE  AND  TOXICOLOGY. 

Edited  by  Frederick  Peterson,  M.D.,  Clinical  Professor  of  Mental  Diseases  in 
the  Woman's  Medical  College,  New  York ;  Chief  of  Clinic,  Nervous  Department, 
College  of  Physicians  and  Surgeons,  Newr  York;  and  Walter  S.  Haines,  M.D., 
Professor  of  Chemistry,  Pharmacy,  and  Toxicology  in  Rush  Medical  College,  Chicago, 
Illinois. 

STENGEL'S  PATHOLOGY. 

A  Manual  of  Pathology.  By  Alfred  Stengel,  ISI.  D.,  Physician  to  the 
Philadelphia  Hospital ;  Professor  of  Clinical  Medicine  in  the  Woman's  Medical 
College ;  Physician  to  the  Children's  Hospital ;  late  Pathologist  to  the  German 
Hospital,  Philadelphia,  etc. 

CHURCH  AND  PETERSON'S  NERVOUS  AND  MENTAL  DISEASES. 

Nervous  and  Mental  Diseases.  By  Archibald  Church,  M.D.,  Professor  of 
Mental  Diseases  and  Medical  Jurisprudence  in  the  Northwestern  University  Medical 
School,  Chicago ;  and  Frederick  Peterson,  M.D. ,  Clinical  Professor  of  Mental 
Diseases  in  the  Woman's  Medical  College,  New  York  ;  Chief  of  Clinic,  Nervous 
Department,  College  of  Physicians  and  Surgeons,  New  York. 

HEISLER'S  EMBRYOLOGY. 

A  Text=Book  of  Embryology.  By  John  C.  Heisler,  M.D.,  Professcnr  of 
Anatomy  in  the  Medico-Chirurgical  College,  Philadelphia. 

KYLE  ON  THE  NOSE  AND  THROAT. 

Diseases  of  the  Nose  and  Throat.  By  D.  Braden  Kyle,  M.  D.,  Clinical  Pro- 
fessor of  Laryngology  and  Rhinology.  Jefferson  Medical  College,  Philadelphia;  Con- 
sulting Earyngologist,  Rhinologist,  and  Otologist,  St.  Agnes'  Hospital ;  Bacteriologist 
to  the  Philadelphia  Orthopedic  Hospital  and  Infirmary  for  Nervous  Diseases,  etc. 

HIRST'S  OBSTETRICS. 

A  Text=Book  of  Obstetrics.  By  Barton  Cooke  Hirst,  M.D.,  Professor  of 
Obstetrics  in  the  University  of  Pennsylvania. 

WEST'S  NURSING. 

An  American  Text-Book  of  Nursing.  By  American  Teachers.  Edited  by 
Roberta  M.  West,  Late  Superintendent  of  Nurses  in  the  Hospital  of  the  University 
of  Pennsylvania. 


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MacDonald 

Clinical  text-book  of  surgical 
diagnosis   and  treatment. 

im 

